Provider Demographics
NPI:1477635357
Name:EDWARDS, BRUCE L (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:EDWARDS
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 1:321 CROSSWAYS PARK DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-2066
Mailing Address - Country:US
Mailing Address - Phone:516-933-1125
Mailing Address - Fax:516-822-8424
Practice Address - Street 1:321 CROSSWAYS PARK DR STE 1A
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-2066
Practice Address - Country:US
Practice Address - Phone:516-933-1125
Practice Address - Fax:516-822-8424
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159998207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D91825Medicare UPIN
15F381Medicare ID - Type Unspecified