Provider Demographics
NPI:1225091051
Name:EVENCHIK, BRUCE G (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:G
Last Name:EVENCHIK
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 1:820 UNION ST.
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534
Mailing Address - Country:US
Mailing Address - Phone:518-828-3391
Mailing Address - Fax:518-828-6734
Practice Address - Street 1:820 UNION ST.
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534
Practice Address - Country:US
Practice Address - Phone:518-828-3391
Practice Address - Fax:518-828-6734
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148821207W00000X
MA47753207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1010050002OtherGB MEDICARE NSC
MA0154954Medicaid
MAI22279Medicare ID - Type Unspecified
MA1010050001Medicare NSC
MA1010050002OtherGB MEDICARE NSC
MAA66251Medicare UPIN