Provider Demographics
NPI:1285618058
Name:ABBOTT, BRUCE E (DPM)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125
Mailing Address - Country:US
Mailing Address - Phone:724-588-6160
Mailing Address - Fax:724-588-0122
Practice Address - Street 1:110 WOODFIELD DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125
Practice Address - Country:US
Practice Address - Phone:724-588-6160
Practice Address - Fax:724-588-0122
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002545L213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010401540003Medicaid
PA0518630001Medicare NSC
122341Medicare PIN
PA0010401540003Medicaid