Provider Demographics
NPI:1164587036
Name:JANELLI, BRUCE D (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:JANELLI
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 1:76 CHURCH ST
Mailing Address - Street 2:BOX 817
Mailing Address - City:CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06018-2447
Mailing Address - Country:US
Mailing Address - Phone:860-824-0731
Mailing Address - Fax:
Practice Address - Street 1:76 CHURCH ST
Practice Address - Street 2:BOX 817
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2447
Practice Address - Country:US
Practice Address - Phone:860-824-0731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB83434Medicare UPIN
CT110001113Medicare ID - Type Unspecified