Provider Demographics
NPI:1821521279
Name:LEEWIWATANAKUL, BRUCE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:LEEWIWATANAKUL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 CIVIC CENTER BLVD DIVISION OF POST PEDS PORTAL
Mailing Address - Street 2:FELLOWSHIP IN GENERAL & CHILD AND ADOLESCENT PSYCHIATRY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-327-4438
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD DIVISION OF POST PEDS PORTAL
Practice Address - Street 2:FELLOWSHIP IN GENERAL & CHILD AND ADOLESCENT PSYCHIATRY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-327-4438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO197940208000000X
PAOS0212272084P0800X, 2084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program