Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 036-0002195093-04 | WI |
NPI | 1457894404 |
---|---|
Provider Name | Charles Timothy Brakefield |
First Address | Madison, WI 53705-2288 |
Second Address | Madison, WI 53719-1126 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/11/2016 |
Last Update Date | 22/08/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0829340001 | MEDICARE PTAN (01) | WI |
41744100 | (05) | WI |