Basic Information
| Provider Information | |||||||||
| NPI: | 1356792352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCKNER | ||||||||
| FirstName: | MADALYNN | ||||||||
| MiddleName: | DIANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 506 WABASH AVENUE | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478073525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122320073 | ||||||||
| FaxNumber: | 8122320074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2016 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003979A | IN | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.