Provider Demographics
NPI:1790248656
Name:BRUCH, HEIDI ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:ANN
Last Name:BRUCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 LILLY HILL RD
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:PA
Mailing Address - Zip Code:18014-9566
Mailing Address - Country:US
Mailing Address - Phone:610-704-0807
Mailing Address - Fax:
Practice Address - Street 1:2030 W TILGHMAN ST STE 101
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-4354
Practice Address - Country:US
Practice Address - Phone:610-432-3258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEGOO3542152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program