Healthcare Provider Details

I. General information

NPI: 1588661854
Provider Name (Legal Business Name): BRUCE BOLASNY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WOLF CREEK BLVD SUITE 1
DOVER DE
19901-4915
US

IV. Provider business mailing address

103 WOLF CREEK BLVD SUITE 1
DOVER DE
19901-4915
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-2420
  • Fax: 302-674-4473
Mailing address:
  • Phone: 302-674-2420
  • Fax: 302-674-4473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC1-0000582
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: