=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609853076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE DANIEL WILLNER DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2005
-----------------------------------------------------
Last Update Date | 09/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3622 BELMONT AVE STE 18
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44505-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-759-8050
-----------------------------------------------------
Fax | 330-759-1246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3622 BELMONT AVE STE 18
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44505-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-759-8050
-----------------------------------------------------
Fax | 330-759-1246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 34004681W
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------