Healthcare Provider Details

I. General information

NPI: 1912226861
Provider Name (Legal Business Name): JEFFREY T BRUCKEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 06/28/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S CLINTON AVE BLDG G
ROCHESTER NY
14618-2668
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 679-B
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-7800
  • Fax:
Mailing address:
  • Phone: 585-275-2475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number254831
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number284123
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number284123
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: