Provider Demographics
NPI:1992966022
Name:BUSH, BROOKE HEINEMAN (OD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:HEINEMAN
Last Name:BUSH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:JASMINE
Other - Last Name:HEINEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3460 GOLFVIEW DR
Mailing Address - Street 2:APT. 2213
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2440
Mailing Address - Country:US
Mailing Address - Phone:507-884-9474
Mailing Address - Fax:
Practice Address - Street 1:19022 FREEPORT ST NW
Practice Address - Street 2:#H
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-4766
Practice Address - Country:US
Practice Address - Phone:763-441-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist