Provider Demographics
NPI:1750494613
Name:DECOTIIS, BRUCE ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ANTHONY
Last Name:DECOTIIS
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 1:1673 HIGHWAY 88 WEST
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724
Mailing Address - Country:US
Mailing Address - Phone:732-458-2000
Mailing Address - Fax:732-458-4523
Practice Address - Street 1:1673 HIGHWAY 88 WEST
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724
Practice Address - Country:US
Practice Address - Phone:732-458-2000
Practice Address - Fax:732-458-4523
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ032368207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4770005Medicaid
NJ785112Medicare ID - Type Unspecified
NJ4770005Medicaid