Provider Demographics
NPI:1194827584
Name:KOKERNOT, BRUCE GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:GLENN
Last Name:KOKERNOT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:518-952-8408
Mailing Address - Fax:518-399-6860
Practice Address - Street 1:80 SHARRON AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-4700
Practice Address - Country:US
Practice Address - Phone:518-561-1447
Practice Address - Fax:518-562-8812
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2021-05-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY2122322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid
NY01420800Medicaid