Provider Demographics
NPI:1871581330
Name:JURGENS, BRIAN J (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:JURGENS
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 1:2300 N MAYFAIR RD
Mailing Address - Street 2:#1155
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1505
Mailing Address - Country:US
Mailing Address - Phone:414-258-6880
Mailing Address - Fax:414-258-5686
Practice Address - Street 1:2300 N MAYFAIR RD
Practice Address - Street 2:#1155
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1505
Practice Address - Country:US
Practice Address - Phone:414-258-6880
Practice Address - Fax:414-258-5686
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38589600Medicaid
WI000801770Medicare ID - Type Unspecified
WI38589600Medicaid