Provider Demographics
NPI:1922119486
Name:BRUESCH, RICHARD DAVID (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:BRUESCH
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 1:13941 REDWOOD ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4135
Mailing Address - Country:US
Mailing Address - Phone:651-464-9767
Mailing Address - Fax:
Practice Address - Street 1:200 12TH ST SW
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1482
Practice Address - Country:US
Practice Address - Phone:651-464-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5C945BROtherBC/BS GRP #
MN5C946BROtherBC/BS IND #
MNBR746478OtherCLARITY VISION
MN152233OtherCOLE VISION
MN412481029770OtherPREFERREDONE
MN922683OtherBLOCK VISION
MN16824OtherSPECTERA
MN2100260OtherMEDICA DISP
MN2201835OtherMEDICA
MN49536OtherDAVIS VISION
MN5C945BROtherBC/BS GRP #