Provider Demographics
NPI:1861423519
Name:BRUNSEN, BLAINE R (OD)
Entity type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:R
Last Name:BRUNSEN
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 1:2628 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-3908
Mailing Address - Country:US
Mailing Address - Phone:515-274-4141
Mailing Address - Fax:
Practice Address - Street 1:2628 BEAVER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3908
Practice Address - Country:US
Practice Address - Phone:515-274-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2057152W00000X
IA002417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist