Provider Demographics
NPI:1386622470
Name:BRUSKOFF, BRUCE L (DPM)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:BRUSKOFF
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 1:1304 RHAWN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2870
Mailing Address - Country:US
Mailing Address - Phone:215-514-8652
Mailing Address - Fax:
Practice Address - Street 1:1304 RHAWN ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19111-2870
Practice Address - Country:US
Practice Address - Phone:215-742-1225
Practice Address - Fax:215-742-3902
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA213E00000X213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000500788-0007Medicaid
PA000500788-0006Medicaid