Provider Demographics
NPI:1164509444
Name:BRUNO, BASIL (MD)
Entity Type:Individual
Prefix:DR
First Name:BASIL
Middle Name:
Last Name:BRUNO
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 1:18 RAILROAD AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-4105
Mailing Address - Country:US
Mailing Address - Phone:201-928-0748
Mailing Address - Fax:201-928-0842
Practice Address - Street 1:18 RAILROAD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCHELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07662-4105
Practice Address - Country:US
Practice Address - Phone:201-928-0748
Practice Address - Fax:201-928-0842
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA055053207Q00000X
NY270553207Q00000X
NJ25MA05505300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6029701Medicaid