Provider Demographics
NPI:1720261274
Name:DR. BRUCE DORMAN, D.P.M.
Entity Type:Organization
Organization Name:DR. BRUCE DORMAN, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-454-4333
Mailing Address - Street 1:6134 188TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2726
Mailing Address - Country:US
Mailing Address - Phone:718-454-4333
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY003551332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4224860001Medicare NSC