Provider Demographics
NPI:1861934945
Name:GUTELIUS, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GUTELIUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 28TH ST
Mailing Address - Street 2:WS 06-01
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-4130
Mailing Address - Country:US
Mailing Address - Phone:347-396-2617
Mailing Address - Fax:
Practice Address - Street 1:4209 28TH ST
Practice Address - Street 2:WS 06-01
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4130
Practice Address - Country:US
Practice Address - Phone:347-396-2617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248832-1207R00000X
ORMD1671442083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine