Provider Demographics
NPI:1346254471
Name:SANDEROV, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:SANDEROV
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 1:519 W JERICHO TPKE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2619
Mailing Address - Country:US
Mailing Address - Phone:631-360-5900
Mailing Address - Fax:631-360-9403
Practice Address - Street 1:519 W JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2619
Practice Address - Country:US
Practice Address - Phone:631-360-5900
Practice Address - Fax:631-360-9403
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152464-1207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1115475Medicaid
NY035D95Medicare ID - Type Unspecified
NY1115475Medicaid