1750364972 NPI number — BRUCE M MCDONALD MD

Table of content: BRUCE M MCDONALD MD (NPI 1750364972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750364972 NPI number — BRUCE M MCDONALD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONALD
Provider First Name:
BRUCE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750364972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-5126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-384-3975
Provider Business Mailing Address Fax Number:
203-384-3829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
267 GRANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06610-2805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-384-3717
Provider Business Practice Location Address Fax Number:
203-384-4132
Provider Enumeration Date:
11/22/2005

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: 2080P0210X , with the licence number:  020490 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001204908 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com