Provider Demographics
NPI:1134296395
Name:WISHNOV, BRUCE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:WISHNOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22065 STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4219
Mailing Address - Country:US
Mailing Address - Phone:561-488-4847
Mailing Address - Fax:561-488-4366
Practice Address - Street 1:22065 STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-4219
Practice Address - Country:US
Practice Address - Phone:561-488-4847
Practice Address - Fax:561-488-4366
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAW2816556OtherDEA
FLE32293Medicare UPIN
82731Medicare ID - Type Unspecified