Provider Demographics
NPI:1952796567
Name:BUGENSKE, ELISE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:
Last Name:BUGENSKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2230 TOWNE LAKE PKWY BLDG 600 STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-2607
Mailing Address - Country:US
Mailing Address - Phone:770-591-3511
Mailing Address - Fax:770-591-3752
Practice Address - Street 1:2230 TOWNE LAKE PKWY BLDG 600 STE 100
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-2607
Practice Address - Country:US
Practice Address - Phone:770-591-3511
Practice Address - Fax:770-591-3752
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002863152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist