Provider Demographics
NPI:1043220130
Name:BRUCH, JEAN ANN (OD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
Last Name:BRUCH
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 1:647 S R 93 VALLEY PLAZA
Mailing Address - Street 2:P O BOX 752
Mailing Address - City:CONYNGHAM
Mailing Address - State:PA
Mailing Address - Zip Code:18219-0752
Mailing Address - Country:US
Mailing Address - Phone:570-788-4133
Mailing Address - Fax:570-788-2876
Practice Address - Street 1:647 S R 93
Practice Address - Street 2:VALLEY PLAZA STE 7
Practice Address - City:CONYNGHAM
Practice Address - State:PA
Practice Address - Zip Code:18219-0752
Practice Address - Country:US
Practice Address - Phone:570-788-4133
Practice Address - Fax:570-788-2876
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT29989Medicare UPIN
PABR183218Medicare ID - Type Unspecified