Provider Demographics
NPI:1457353856
Name:DORMAN, BRUCE ALAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:DORMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HIGHTOP LN
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1719
Mailing Address - Country:US
Mailing Address - Phone:516-938-2055
Mailing Address - Fax:718-454-4823
Practice Address - Street 1:6134 188TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2726
Practice Address - Country:US
Practice Address - Phone:718-454-4333
Practice Address - Fax:718-454-4823
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY003551213E00000X
FL1495213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0025415OtherGHI
NY00818933Medicaid
NYP38382OtherBLUE CROSS
NYP559929OtherOXFORD INSURANCE
NYP559929OtherOXFORD INSURANCE
NYP38381Medicare ID - Type UnspecifiedBLUE CROSS MEDICARE
NY00818933Medicaid