Provider Demographics
NPI:1750364972
Name:MCDONALD, BRUCE M (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415126
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5126
Mailing Address - Country:US
Mailing Address - Phone:203-384-3975
Mailing Address - Fax:203-384-3829
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2805
Practice Address - Country:US
Practice Address - Phone:203-384-3717
Practice Address - Fax:203-384-4132
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0204902080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001204908Medicaid
CTD400012448Medicare PIN
E31768Medicare UPIN