Provider Demographics
NPI:1053413484
Name:BRUNO, NICHOLAS PAUL (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PAUL
Last Name:BRUNO
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 1:741 SMITH STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3592
Mailing Address - Country:US
Mailing Address - Phone:401-421-7656
Mailing Address - Fax:401-270-6457
Practice Address - Street 1:3 WAKE ROBIN RD UNIT 5
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4208
Practice Address - Country:US
Practice Address - Phone:401-475-9140
Practice Address - Fax:401-475-2808
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI5860207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9000499Medicaid
RI079000499Medicare ID - Type Unspecified
RI9000499Medicaid