Healthcare Provider Details

I. General information

NPI: 1750364972
Provider Name (Legal Business Name): BRUCE M MCDONALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 GRANT ST
BRIDGEPORT CT
06610-2805
US

IV. Provider business mailing address

PO BOX 415126
BOSTON MA
02241-5126
US

V. Phone/Fax

Practice location:
  • Phone: 203-384-3717
  • Fax: 203-384-4132
Mailing address:
  • Phone: 203-384-3975
  • Fax: 203-384-3829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number020490
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001204908
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: