Healthcare Provider Details

I. General information

NPI: 1689403461
Provider Name (Legal Business Name): BRUNO MARCON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 CHURCHMANS ROAD
NEWARK DE
19702
US

IV. Provider business mailing address

105 MILHOLLAN DRIVE
ELKTON MD
21921
US

V. Phone/Fax

Practice location:
  • Phone: 302-544-5055
  • Fax:
Mailing address:
  • Phone: 443-553-0781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberU1-0012654
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: