Provider Demographics
NPI:1306159421
Name:CRUSBERG, WENDY KATHLEEN (OD)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:KATHLEEN
Last Name:CRUSBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:KATHLEEN
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:545 HOOKSETT RD
Mailing Address - Street 2:UNIT 23
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-2654
Mailing Address - Country:US
Mailing Address - Phone:603-622-6333
Mailing Address - Fax:603-627-4619
Practice Address - Street 1:545 HOOKSETT RD UNIT 23
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2654
Practice Address - Country:US
Practice Address - Phone:603-622-6333
Practice Address - Fax:603-627-4619
Is Sole Proprietor?:No
Enumeration Date:2010-07-18
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30358259Medicaid