Provider Demographics
NPI:1114971835
Name:BRUCKSTEIN, ALEX HARRY (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:HARRY
Last Name:BRUCKSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4339
Mailing Address - Country:US
Mailing Address - Phone:718-667-3200
Mailing Address - Fax:718-667-6615
Practice Address - Street 1:2627 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4339
Practice Address - Country:US
Practice Address - Phone:718-667-3200
Practice Address - Fax:718-667-6615
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY129764207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY325101OtherMEDICARE PTAN
NY325101OtherMEDICARE PTAN