Provider Demographics
NPI:1417010745
Name:BRUSGARD-CERRA, MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:
Last Name:BRUSGARD-CERRA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MARIE
Other - Middle Name:BRUSGARD
Other - Last Name:CERRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1004 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2604
Mailing Address - Country:US
Mailing Address - Phone:732-615-9300
Mailing Address - Fax:732-615-9302
Practice Address - Street 1:1004 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2604
Practice Address - Country:US
Practice Address - Phone:732-615-9300
Practice Address - Fax:732-615-9302
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00485200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ109639WCZMedicare PIN
NJT84908Medicare UPIN