Provider Demographics
NPI:1336146596
Name:MCLAUGHLIN, BRUCE J
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:MCLAUGHLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4910
Mailing Address - Country:US
Mailing Address - Phone:631-422-4450
Mailing Address - Fax:631-422-4451
Practice Address - Street 1:1111 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4910
Practice Address - Country:US
Practice Address - Phone:631-422-4450
Practice Address - Fax:631-422-4451
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-02
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003264213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00713364Medicaid
NYT51111Medicare UPIN
NY00713364Medicaid