Provider Demographics
NPI:1346233194
Name:SHAFFER, BRUCE MARSHALL (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MARSHALL
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:667 STONELEIGH AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-2454
Mailing Address - Country:US
Mailing Address - Phone:845-278-8637
Mailing Address - Fax:845-278-8695
Practice Address - Street 1:667 STONELEIGH AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-2454
Practice Address - Country:US
Practice Address - Phone:845-278-8637
Practice Address - Fax:845-278-8695
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYN2987213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00419452Medicaid
T50495Medicare UPIN
NY0547970002Medicare NSC
NY00419452Medicaid