Provider Demographics
NPI:1386644375
Name:BRUCKSTEIN, ROBERT L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:BRUCKSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
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:516-371-2251
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:516-371-2251
Is Sole Proprietor?:No
Enumeration Date:2005-07-31
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY117212-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00216904Medicaid
NY00216904Medicaid