Provider Demographics
NPI:1962506204
Name:WAINER, BRUCE P (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:P
Last Name:WAINER
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 1:1825 BARNUM AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5333
Mailing Address - Country:US
Mailing Address - Phone:203-377-5493
Mailing Address - Fax:203-380-0874
Practice Address - Street 1:1825 BARNUM AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5333
Practice Address - Country:US
Practice Address - Phone:203-377-5493
Practice Address - Fax:203-380-0874
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025902207RE0101X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1259027Medicaid
CT110001198Medicare PIN
C65135Medicare UPIN
CT1259027Medicaid