Provider Demographics
NPI:1356389506
Name:BRUNSWICK, AMY J
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:J
Last Name:BRUNSWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-4604
Mailing Address - Country:US
Mailing Address - Phone:419-782-3937
Mailing Address - Fax:419-782-3930
Practice Address - Street 1:283 STADIUM DR
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-4604
Practice Address - Country:US
Practice Address - Phone:419-782-3937
Practice Address - Fax:419-782-3930
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4788/T1594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2988334Medicaid
0814765Medicare PIN
OH2988334Medicaid