Provider Demographics
NPI:1952378507
Name:LAZARUS, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:LAZARUS
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 1:111 BREWSTER ST
Mailing Address - Street 2:DEPT. OF PHYSICAL MEDICINE / REHABILITATION
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4400
Mailing Address - Country:US
Mailing Address - Phone:401-729-2326
Mailing Address - Fax:401-729-2243
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:DEPT. OF PHYSICAL MEDICINE / REHABILITATION
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4400
Practice Address - Country:US
Practice Address - Phone:401-729-2326
Practice Address - Fax:401-729-2243
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD07243208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007057387OtherMEDICARE PTAN
RI9006444Medicaid
RIC90174Medicare UPIN