Provider Demographics
NPI:1043403967
Name:VANDRIEL, BUSISIWE ROSE (OD)
Entity Type:Individual
Prefix:
First Name:BUSISIWE
Middle Name:ROSE
Last Name:VANDRIEL
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 1:200 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4252
Mailing Address - Country:US
Mailing Address - Phone:715-842-8040
Mailing Address - Fax:715-848-8773
Practice Address - Street 1:200 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4252
Practice Address - Country:US
Practice Address - Phone:715-842-8040
Practice Address - Fax:715-848-8773
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3085-035152W00000X
MN3081152W00000X
WA00004168152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38632500Medicaid
WI001247342Medicare PIN