Provider Demographics
NPI:1912004805
Name:LOWELL, BRUCE KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:KENNETH
Last Name:LOWELL
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 1:1000 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5312
Mailing Address - Country:US
Mailing Address - Phone:516-482-0162
Mailing Address - Fax:516-482-0165
Practice Address - Street 1:1000 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5312
Practice Address - Country:US
Practice Address - Phone:516-482-0162
Practice Address - Fax:516-482-0165
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133929-1207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00385433Medicaid
NY00385433Medicaid
NYB88881Medicare UPIN