1831187434 NPI number — DR. BRUCE PRESTON THEALL DPM

Table of content: DR. BRUCE PRESTON THEALL DPM (NPI 1831187434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831187434 NPI number — DR. BRUCE PRESTON THEALL DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEALL
Provider First Name:
BRUCE
Provider Middle Name:
PRESTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THEALL
Provider Other First Name:
BRUCE
Provider Other Middle Name:
PRESTON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1831187434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
EAST ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07018-2835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-673-3668
Provider Business Mailing Address Fax Number:
862-252-9542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
EAST ORANGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07018-2835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-673-3668
Provider Business Practice Location Address Fax Number:
862-252-9542
Provider Enumeration Date:
10/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  25MD00131000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4548860001 . This is a "MEDICARE NSC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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