Provider Demographics
NPI:1245305887
Name:YUDELSON, BRUCE D (DOCTOR OF AUDIOLOGY)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
Last Name:YUDELSON
Suffix:
Gender:M
Credentials:DOCTOR OF AUDIOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 LAWRENCE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-979-2419
Mailing Address - Fax:631-979-2203
Practice Address - Street 1:90 LAWRENCE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-979-2419
Practice Address - Fax:631-979-2203
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY737231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM01351Medicare ID - Type Unspecified