Provider Demographics
NPI:1093771354
Name:CONAN, BRUCE HOWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:HOWARD
Last Name:CONAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 W BROWARD BLVD
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-3756
Mailing Address - Country:US
Mailing Address - Phone:954-583-1311
Mailing Address - Fax:954-587-4448
Practice Address - Street 1:4320 W BROWARD BLVD
Practice Address - Street 2:SUITE # 2
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3756
Practice Address - Country:US
Practice Address - Phone:954-583-1311
Practice Address - Fax:954-587-4448
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084459400Medicaid
FL19539Medicare ID - Type Unspecified
FL084459400Medicaid