Provider Demographics
NPI:1558378760
Name:WASKOWICZ, BRUCE C (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:WASKOWICZ
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:TERRE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17581-0130
Mailing Address - Country:US
Mailing Address - Phone:717-445-4576
Mailing Address - Fax:717-445-4483
Practice Address - Street 1:770 BROAD STRET
Practice Address - Street 2:
Practice Address - City:EAST EARL
Practice Address - State:PA
Practice Address - Zip Code:17519
Practice Address - Country:US
Practice Address - Phone:717-445-4576
Practice Address - Fax:717-445-4483
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043260L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA679064OtherBLUE SHIELD
PA0012519450003Medicaid
PA50051166OtherCAPITAL BLUE
PAP002394OtherGATEWAY
PAP00259886OtherRR MCR
PA574317OtherAETNA
PA50051166OtherCAPITAL BLUE
PA0012519450003Medicaid