Provider Demographics
NPI:1912115999
Name:DR RICHARD D BRUESCH, PA
Entity Type:Organization
Organization Name:DR RICHARD D BRUESCH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUESCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-464-9767
Mailing Address - Street 1:200 12TH ST SW
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1482
Mailing Address - Country:US
Mailing Address - Phone:651-464-9767
Mailing Address - Fax:651-464-9062
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:651-464-9062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN21000260OtherMEDICA
MN2201835OtherMEDICA
MN5C945BROtherBCBS OF MN
MN5C946BROtherBCBS OF MN
MN167933OtherUCARE
MN412481029770OtherPREFERREDONE
MN=========OtherAETNA
MN=========OtherPATIENTS CHOICE
MN167933OtherUCARE
MN5C946BROtherBCBS OF MN
MN=========OtherCIGNA
MN5C946BROtherBCBS OF MN