Provider Demographics
NPI:1699723965
Name:CARDONE, BRUCE W (MD, RVT, RPHS)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:CARDONE
Suffix:
Gender:M
Credentials:MD, RVT, RPHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19685 WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2225
Mailing Address - Country:US
Mailing Address - Phone:262-391-5000
Mailing Address - Fax:815-550-0061
Practice Address - Street 1:3871 N PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8080
Practice Address - Country:US
Practice Address - Phone:815-397-5554
Practice Address - Fax:815-550-0051
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200317682085R0202X
WI308902085R0202X
IL0360736282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073628Medicaid
WI32047900Medicaid
WIE85252Medicare UPIN