Provider Demographics
NPI:1033161120
Name:BRUGGEMAN, JERRY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JOSEPH
Last Name:BRUGGEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:910 N COLLEGE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4797
Mailing Address - Country:US
Mailing Address - Phone:636-642-1215
Mailing Address - Fax:573-234-4799
Practice Address - Street 1:910 N COLLEGE AVE STE 4
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4797
Practice Address - Country:US
Practice Address - Phone:636-642-1215
Practice Address - Fax:573-234-4799
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004011867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207251901Medicaid