Provider Demographics
NPI:1184788333
Name:MACDONALD, ROBERT BRUCE (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRUCE
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 ROANOKE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2778
Mailing Address - Country:US
Mailing Address - Phone:631-369-5361
Mailing Address - Fax:631-369-9423
Practice Address - Street 1:223 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2778
Practice Address - Country:US
Practice Address - Phone:631-369-5361
Practice Address - Fax:631-369-9423
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015564-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY065838Medicare UPIN
NYV2C551Medicare ID - Type UnspecifiedMEDICARE