Provider Demographics
NPI:1790836401
Name:BRUEGGEMAN, JONATHAN N (DPM)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:N
Last Name:BRUEGGEMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-483-1060
Mailing Address - Fax:906-483-1270
Practice Address - Street 1:500 CAMPUS DRIVE
Practice Address - Street 2:SUITE 2
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-1569
Practice Address - Country:US
Practice Address - Phone:906-483-1060
Practice Address - Fax:906-483-1270
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005289213ES0103X
WI954-25213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI02120-0301Medicare PIN
WI68015-0100Medicare PIN