Provider Demographics
NPI:1396890075
Name:BRUCK, LANCE RICHARD
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:RICHARD
Last Name:BRUCK
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 1:42 ROCK SHELTER RD
Mailing Address - Street 2:
Mailing Address - City:WACCABUC
Mailing Address - State:NY
Mailing Address - Zip Code:10597-1034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 TENBROECK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2007
Practice Address - Country:US
Practice Address - Phone:718-430-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200006207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01833898Medicaid