Provider Demographics
NPI:1265096911
Name:GRATTAN, BRUCE JOHN JR (DO, MS, RD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JOHN
Last Name:GRATTAN
Suffix:JR
Gender:M
Credentials:DO, MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BRICKHILL AVE UNIT 346
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2188
Mailing Address - Country:US
Mailing Address - Phone:860-933-1339
Mailing Address - Fax:
Practice Address - Street 1:GOUVERNEUR HOSPITAL
Practice Address - Street 2:77 WEST BARNEY STREET
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1040
Practice Address - Country:US
Practice Address - Phone:315-287-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.015003207P00000X
390200000X
NY316792207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program