Provider Demographics
NPI:1285616276
Name:HOLBROOK, STEVEN EUGENE (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:EUGENE
Last Name:HOLBROOK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2216
Mailing Address - Country:US
Mailing Address - Phone:812-334-1213
Mailing Address - Fax:812-333-5039
Practice Address - Street 1:1011 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2216
Practice Address - Country:US
Practice Address - Phone:812-334-1213
Practice Address - Fax:812-333-5039
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002903A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200153550AMedicaid
INT93974Medicare UPIN
IN549330AMedicare ID - Type Unspecified