Provider Demographics
NPI:1992913016
Name:LIZERBRAM, BRUCE (DO)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:LIZERBRAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14200 BUSTLETON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-1186
Mailing Address - Country:US
Mailing Address - Phone:215-514-7986
Mailing Address - Fax:215-493-0752
Practice Address - Street 1:14200 BUSTLETON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-1186
Practice Address - Country:US
Practice Address - Phone:215-514-7986
Practice Address - Fax:215-493-0752
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-005235-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB42115Medicare UPIN