Provider Demographics
NPI:1699007211
Name:FOGEL, BRUCE J (ORTHOTIST)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:J
Last Name:FOGEL
Suffix:
Gender:M
Credentials:ORTHOTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4904
Mailing Address - Country:US
Mailing Address - Phone:516-495-7777
Mailing Address - Fax:
Practice Address - Street 1:510 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4904
Practice Address - Country:US
Practice Address - Phone:516-495-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCO1972172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5021150002Medicare NSC