Provider Demographics
NPI:1477863280
Name:BRUCE SENIOR OD PA
Entity Type:Organization
Organization Name:BRUCE SENIOR OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:SENIOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-337-2020
Mailing Address - Street 1:2277 FIRST ST.
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-2959
Mailing Address - Country:US
Mailing Address - Phone:239-337-2020
Mailing Address - Fax:239-337-7652
Practice Address - Street 1:2277 FIRST ST.
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-2959
Practice Address - Country:US
Practice Address - Phone:239-337-2020
Practice Address - Fax:239-337-7652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0001000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084290700Medicaid
FLT-83990Medicare UPIN
FL084290700Medicaid