Provider Demographics
NPI:1164409348
Name:BOURGERIE, JEFFERY R (OD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:R
Last Name:BOURGERIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E BROADWAY AVE
Mailing Address - Street 2:P.O. BOX 547
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1835
Mailing Address - Country:US
Mailing Address - Phone:715-748-2020
Mailing Address - Fax:715-748-4565
Practice Address - Street 1:309 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1835
Practice Address - Country:US
Practice Address - Phone:715-748-2020
Practice Address - Fax:715-748-4565
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38715300Medicaid
WI37815100Medicaid
WI39-1229699OtherFEDERAL TAX ID-MEDFORD
WI391229699015OtherBLUE CROSS BLUE SHIELD-ME
WI0474980001OtherDMERC-MEDFORD GROUP
WI10445OtherNVA-MEDFORD
WI410045063OtherRAILROAD MEDICARE-COLBY
WI1271670001OtherDMERC-COLBY GROUP
WI21143OtherSECURITY HEALTH PLAN-MEDF
WI2228OtherLICENSE NUMBER
WI39-1967186OtherFEDERALTAX ID-COLBY
WI38581200Medicaid
WI391967186091OtherBLUE CROSS BLUE SHIELD-CO
WI410015253OtherRAILROAD MEDICARE-MEDFORD
WI63857OtherSECURITY HEALTH PLAN-COLB
WI63857OtherSECURITY HEALTH PLAN-COLB