Individual
JEFFERY R BOURGERIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
309 E BROADWAY AVE, MEDFORD, WI 54451-1835
(715) 748-2020
(715) 748-4565
Mailing address
309 E BROADWAY AVE, P.O. BOX 547, MEDFORD, WI 54451-1835
(715) 748-2020
(715) 748-4565
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2228
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0474980001
DMERC-MEDFORD GROUP
WI
01
—
10445
NVA-MEDFORD
WI
01
—
1271670001
DMERC-COLBY GROUP
WI
01
—
21143
SECURITY HEALTH PLAN-MEDF
WI
01
—
2228
LICENSE NUMBER
WI
05
—
37815100
—
WI
05
—
38581200
—
WI
05
—
38715300
—
WI
01
—
39-1229699
FEDERAL TAX ID-MEDFORD
WI
01
—
39-1967186
FEDERALTAX ID-COLBY
WI
01
—
391229699015
BLUE CROSS BLUE SHIELD-ME
WI
01
—
391967186091
BLUE CROSS BLUE SHIELD-CO
WI
01
—
410015253
RAILROAD MEDICARE-MEDFORD
WI
01
—
410045063
RAILROAD MEDICARE-COLBY
WI
01
—
63857
SECURITY HEALTH PLAN-COLB
WI
Enumeration date
12/28/2005
Last updated
03/07/2023
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