Provider Demographics
NPI:1366433716
Name:SMITH, BRUCE D (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:SMITH
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 1:86 STARDUST PL
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77381-6187
Mailing Address - Country:US
Mailing Address - Phone:936-273-1926
Mailing Address - Fax:
Practice Address - Street 1:1401 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6640
Practice Address - Country:US
Practice Address - Phone:956-968-8567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE59412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B47764Medicare UPIN
8B7117Medicare ID - Type Unspecified