Provider Demographics
NPI:1790718013
Name:MANDUCA, BRUNO (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUNO
Middle Name:
Last Name:MANDUCA
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 1:184 HOLDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5159
Mailing Address - Country:US
Mailing Address - Phone:718-815-0710
Mailing Address - Fax:718-761-0711
Practice Address - Street 1:184 HOLDEN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5159
Practice Address - Country:US
Practice Address - Phone:718-815-0710
Practice Address - Fax:718-761-0711
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201385207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01613872Medicaid
NY01613872Medicaid
NYG18356Medicare UPIN