Provider Demographics
NPI:1962471557
Name:BROVENDER, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:BROVENDER
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 1:1559 YORK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-6001
Mailing Address - Country:US
Mailing Address - Phone:212-585-3329
Mailing Address - Fax:212-585-3717
Practice Address - Street 1:1559 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-6001
Practice Address - Country:US
Practice Address - Phone:212-585-3329
Practice Address - Fax:212-585-3717
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170532208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME21558Medicare UPIN