Provider Demographics
NPI:1053303164
Name:BRUEGGEMANN, STEPHEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:BRUEGGEMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-7588
Mailing Address - Country:US
Mailing Address - Phone:812-342-0343
Mailing Address - Fax:
Practice Address - Street 1:6051 CHANNEL DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-7588
Practice Address - Country:US
Practice Address - Phone:812-342-0343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035246207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000089452OtherBS
IN100083420AMedicaid
IN000000089452OtherBS
E03612Medicare UPIN
IN143380AMedicare ID - Type Unspecified