Provider Demographics
NPI:1619068079
Name:GARRISON, BRUCE A (MD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:A
Last Name:GARRISON
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 1:7108 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365
Mailing Address - Country:US
Mailing Address - Phone:718-820-0120
Mailing Address - Fax:718-820-9239
Practice Address - Street 1:7108 PARK AVE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365
Practice Address - Country:US
Practice Address - Phone:718-820-0120
Practice Address - Fax:718-820-9239
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166451207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
25246OtherUS HEALTHCARE
DP133OtherOXFORD
0044176OtherGHI
0457702OtherCIGNA
160007OtherELDER PLAN
205379POtherHIP
166451C48OtherHEALTH FIRST
4C0575OtherHEALTHNET
NY01121508Medicaid
23E341OtherEMPIRE
DP133OtherOXFORD
4C0575OtherHEALTHNET