Provider Demographics
NPI:1366577694
Name:BAVER, BRUCE ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:BAVER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 CORPORAL KENNEDY ST
Mailing Address - Street 2:APT. 2K
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1455
Mailing Address - Country:US
Mailing Address - Phone:718-631-7937
Mailing Address - Fax:732-634-7920
Practice Address - Street 1:1 WOODBRIDGE CTR
Practice Address - Street 2:SUITE 245
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1150
Practice Address - Country:US
Practice Address - Phone:732-855-8522
Practice Address - Fax:732-634-7920
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000583111N00000X
NY004830111N00000X
FL5462111N00000X
NJMC03258111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
BA683317Medicare ID - Type Unspecified
U18966Medicare UPIN