Provider Demographics
NPI:1417124264
Name:BRUCKNER, RICHARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:BRUCKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS RD
Practice Address - Street 2:LEVEL 4
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8111
Practice Address - Country:US
Practice Address - Phone:631-444-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2404682080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine