Provider Demographics
NPI:1376105700
Name:BIRSCHBACH, CORTNEY D (OD)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:D
Last Name:BIRSCHBACH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CORTNEY
Other - Middle Name:D
Other - Last Name:DUDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:355 N PETERS AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8258
Mailing Address - Country:US
Mailing Address - Phone:920-922-7121
Mailing Address - Fax:
Practice Address - Street 1:355 N PETERS AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8258
Practice Address - Country:US
Practice Address - Phone:920-922-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-06
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3576-35152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management