Provider Demographics
NPI:1194002733
Name:ROBERT L BRUCKSTEIN MD PC
Entity Type:Organization
Organization Name:ROBERT L BRUCKSTEIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUCKSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-239-2332
Mailing Address - Street 1:290 CENTRAL AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-8507
Mailing Address - Country:US
Mailing Address - Phone:516-239-2332
Mailing Address - Fax:
Practice Address - Street 1:290 CENTRAL AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-8507
Practice Address - Country:US
Practice Address - Phone:516-239-2332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117212-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00216904Medicaid
B19041Medicare UPIN