Provider Demographics
NPI:1831187434
Name:THEALL, BRUCE PRESTON (DPM)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:PRESTON
Last Name:THEALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:PRESTON
Other - Last Name:THEALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:310 CENTRAL AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2835
Mailing Address - Country:US
Mailing Address - Phone:973-673-3668
Mailing Address - Fax:862-252-9542
Practice Address - Street 1:310 CENTRAL AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2835
Practice Address - Country:US
Practice Address - Phone:973-673-3668
Practice Address - Fax:862-252-9542
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00131000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4548860001OtherMEDICARE NSC
NJ4548860001OtherMEDICARE NSC
NJT77723Medicare UPIN