Provider Demographics
NPI:1588718340
Name:POVOLNY, WILLIAM BRUCE (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRUCE
Last Name:POVOLNY
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 1:680 S ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-4113
Mailing Address - Country:US
Mailing Address - Phone:775-329-6300
Mailing Address - Fax:775-336-0653
Practice Address - Street 1:330 CRAMPTON ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2480
Practice Address - Country:US
Practice Address - Phone:775-336-3700
Practice Address - Fax:775-336-3701
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4887207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016186Medicaid
NVV31149Medicare PIN
NV002016186Medicaid