Provider Demographics
NPI:1356792352
Name:BRUCKNER, MADALYNN DIANNE (OD)
Entity type:Individual
Prefix:MRS
First Name:MADALYNN
Middle Name:DIANNE
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:506 WABASH AVENUE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3525
Practice Address - Country:US
Practice Address - Phone:812-232-0073
Practice Address - Fax:812-232-0074
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003979A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist