Provider Demographics
NPI:1821021445
Name:BRUNELLO, DONNA M (OD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:M
Last Name:BRUNELLO
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 1:2305 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1411
Mailing Address - Country:US
Mailing Address - Phone:262-597-2020
Mailing Address - Fax:262-597-5452
Practice Address - Street 1:2305 30TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1411
Practice Address - Country:US
Practice Address - Phone:262-597-2020
Practice Address - Fax:262-597-5452
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2287152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38594600Medicaid