Healthcare Provider Details

I. General information

NPI: 1780747840
Provider Name (Legal Business Name): BRUCE SEPLOWITZ O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WESTFARMS MALL D111
FARMINGTON CT
06032-2631
US

IV. Provider business mailing address

61 WESTFARMS MALL D111
FARMINGTON CT
06032-2631
US

V. Phone/Fax

Practice location:
  • Phone: 860-561-5687
  • Fax:
Mailing address:
  • Phone: 860-561-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number859
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number859
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: