Provider Demographics
NPI:1467533646
Name:BURSUA, RICHARD G (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:BURSUA
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:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-7889
Mailing Address - Country:US
Mailing Address - Phone:618-997-6438
Mailing Address - Fax:618-997-6430
Practice Address - Street 1:1306 N . RUSSELL ST.
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-997-6438
Practice Address - Fax:618-997-6430
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006213152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046006213Medicaid
IL046006213Medicaid
IL295890Medicare ID - Type Unspecified
IL0183290001Medicare NSC