Provider Demographics
NPI:1023233558
Name:DOUGLAS, BRUCE (OTR LICENSE)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:OTR LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 MIDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1103
Mailing Address - Country:US
Mailing Address - Phone:718-978-3188
Mailing Address - Fax:718-221-5530
Practice Address - Street 1:4319 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3101
Practice Address - Country:US
Practice Address - Phone:718-978-3186
Practice Address - Fax:718-221-5530
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQT5641Medicare PIN
NYQ03232Medicare UPIN