Provider Demographics
NPI:1265552046
Name:BROCA, MARIE-THERE YVONNE (OD)
Entity type:Individual
Prefix:DR
First Name:MARIE-THERE
Middle Name:YVONNE
Last Name:BROCA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:'TERRI'
Other - Middle Name:
Other - Last Name:BROCA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:5040 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1445
Mailing Address - Country:US
Mailing Address - Phone:702-343-3180
Mailing Address - Fax:
Practice Address - Street 1:3396 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3648
Practice Address - Country:US
Practice Address - Phone:702-343-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1713152W00000X
NYTUV 007017152W00000X
NV617152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist