Provider Demographics
NPI:1609853076
Name:WILLNER, BRUCE DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DANIEL
Last Name:WILLNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 BELMONT AVE
Mailing Address - Street 2:STE 18
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1444
Mailing Address - Country:US
Mailing Address - Phone:330-759-8050
Mailing Address - Fax:330-759-1246
Practice Address - Street 1:3622 BELMONT AVE
Practice Address - Street 2:STE 18
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1444
Practice Address - Country:US
Practice Address - Phone:330-759-8050
Practice Address - Fax:330-759-1246
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004681W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0791899Medicaid
OHWI0630161Medicare PIN
E02351Medicare UPIN