Provider Demographics
NPI:1962453589
Name:BJORK, ERIK R (OD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:R
Last Name:BJORK
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 1:105 E WISCONSIN AVE
Mailing Address - Street 2:#206
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3058
Mailing Address - Country:US
Mailing Address - Phone:262-354-8179
Mailing Address - Fax:262-354-8441
Practice Address - Street 1:105 E WISCONSIN AVE
Practice Address - Street 2:#206
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3058
Practice Address - Country:US
Practice Address - Phone:262-354-8179
Practice Address - Fax:262-354-8441
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009823152W00000X
WI3203-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001604768OtherBLUE CROSS BLUE SHIELD
IL046009823Medicaid
WI100035271Medicaid
P00312305OtherRAILROAD MEDICARE
K27779Medicare PIN
IL046009823Medicaid
WI100035271Medicaid
0839990001Medicare NSC
K27781Medicare PIN
K27782Medicare PIN