Provider Demographics
NPI:1720204555
Name:GUBERMAN, BRUCE ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:GUBERMAN
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 1:612 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2104
Mailing Address - Country:US
Mailing Address - Phone:304-525-4202
Mailing Address - Fax:304-525-4231
Practice Address - Street 1:612 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2104
Practice Address - Country:US
Practice Address - Phone:304-525-4202
Practice Address - Fax:304-525-4231
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13133202C00000X
KY21964202C00000X
MO2005012335202C00000X
OH35037538R202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner