1255336467 NPI number — DR. BRUCE WILLIAM PIERSON OD

Table of content: DR. BRUCE WILLIAM PIERSON OD (NPI 1255336467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255336467 NPI number — DR. BRUCE WILLIAM PIERSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIERSON
Provider First Name:
BRUCE
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1255336467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/17/2006
NPI Reactivation Date:
03/24/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 PICKERING STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15825-1242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-849-4602
Provider Business Mailing Address Fax Number:
814-849-3633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 PICKERING STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15825-1242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-849-4602
Provider Business Practice Location Address Fax Number:
814-849-3633
Provider Enumeration Date:
06/15/2005

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: 152W00000X , with the licence number:  OEG000043 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0010041200001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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