Provider Demographics
NPI:1033266218
Name:BRONGERSMA, LUCILLE HESTER (OD)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:HESTER
Last Name:BRONGERSMA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4844 GLENCANNON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7912
Mailing Address - Country:US
Mailing Address - Phone:707-538-2482
Mailing Address - Fax:
Practice Address - Street 1:3925 OLD REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1719
Practice Address - Country:US
Practice Address - Phone:707-566-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8200T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist