Provider Demographics
NPI:1588942379
Name:TIZES, BRUCE RANDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:RANDOLPH
Last Name:TIZES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 BROADWAY
Mailing Address - Street 2:SUITE 6F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2105
Mailing Address - Country:US
Mailing Address - Phone:312-513-6930
Mailing Address - Fax:
Practice Address - Street 1:2112 BROADWAY
Practice Address - Street 2:SUITE 6F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-2105
Practice Address - Country:US
Practice Address - Phone:312-513-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160717207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine