Provider Demographics
NPI:1295785517
Name:WHITLEY, BRUCE HERBERT (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:HERBERT
Last Name:WHITLEY
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 1:130 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-1047
Mailing Address - Country:US
Mailing Address - Phone:317-852-6484
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-554-0000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030043A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine