Basic Information
| Provider Information | |||||||||
| NPI: | 1053338657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DZIURA | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 789 | ||||||||
| Address2: | |||||||||
| City: | LUDLOW | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010560789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135091000 | ||||||||
| FaxNumber: | 4135091003 | ||||||||
| Practice Location | |||||||||
| Address1: | 299 CAREW ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011042301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137489513 | ||||||||
| FaxNumber: | 4137486844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 44997 | MA | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0101X | 44997 | MA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000020248 | 01 | MA | BMC-HEALTHNET | OTHER | 11988 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 449970 | 01 | MA | CONNECTICARE | OTHER | 6182151 | 05 | MA | MEDICAID | J03496 | 01 | MA | BLUE CROSS OF MA | OTHER | 351643 | 01 | MA | HARVARD PILGRIM | OTHER | 044997 | 01 | MA | TUFTS | OTHER | 98149201 | 01 | MA | NETWORK HEALTH | OTHER | 02681827 | 05 | NY | MEDICAID | 220031586 | 01 | MA | RAILROAD MEDICARE | OTHER | 0024836 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 30206819 | 05 | NH | MEDICAID |