Provider Demographics
NPI:1275561482
Name:STORHAUG, BRUCE A (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:STORHAUG
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 1:306 CIRCLE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7750
Mailing Address - Country:US
Mailing Address - Phone:701-780-9654
Mailing Address - Fax:
Practice Address - Street 1:421 DEMERS AVE. NW
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1835
Practice Address - Country:US
Practice Address - Phone:218-773-3438
Practice Address - Fax:218-773-1645
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2162152W00000X
ND452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60458Medicaid
MN349023800Medicaid
MNT66179Medicare UPIN
MN419000971Medicare ID - Type UnspecifiedEAST GRAND FORKS
MN410001924Medicare ID - Type UnspecifiedCROOKSTON