Provider Demographics
NPI:1942400619
Name:BRUCE G. BARRY
Entity Type:Organization
Organization Name:BRUCE G. BARRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-873-2020
Mailing Address - Street 1:105 KINGS LYNN RD
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589
Mailing Address - Country:US
Mailing Address - Phone:608-873-2020
Mailing Address - Fax:
Practice Address - Street 1:105 KINGS LYNN RD
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1999
Practice Address - Country:US
Practice Address - Phone:608-873-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38709100Medicaid
WI0849000001Medicare NSC
WI38709100Medicaid