Basic Information
| Provider Information | |||||||||
| NPI: | 1134429152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CLOCK TOWER CMNS | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105094055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455924915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 FOSTER RD | ||||||||
| Address2: | |||||||||
| City: | HOPEWELL JUNCTION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125336123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452264590 | ||||||||
| FaxNumber: | 8452262465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 53918 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 259019 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03324238 | 05 | NY | MEDICAID |