Provider Demographics
NPI:1558311217
Name:GIRONELLA, BRYAN CLIVE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:CLIVE
Last Name:GIRONELLA
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 1:2200 LINCOLN ST
Mailing Address - Street 2:SHOPKO EYE CARE CENTER
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-3631
Mailing Address - Country:US
Mailing Address - Phone:715-362-4800
Mailing Address - Fax:715-362-4919
Practice Address - Street 1:2200 LINCOLN ST
Practice Address - Street 2:SHOPKO EYE CARE CENTER
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3631
Practice Address - Country:US
Practice Address - Phone:715-362-4800
Practice Address - Fax:715-362-4919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2830-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38617100Medicaid
WI38617100Medicaid