Provider Demographics
NPI:1003870379
Name:STEVENS, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2151 S STARLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5827
Mailing Address - Country:US
Mailing Address - Phone:804-929-8682
Mailing Address - Fax:804-362-2228
Practice Address - Street 1:1806 SUMMIT AVE STE 300
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-4339
Practice Address - Country:US
Practice Address - Phone:804-362-2227
Practice Address - Fax:804-362-2228
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2023-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-151702084P0800X
WI345782084P0800X
VA01012446882084P0800X
WAMD.MD.611135302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06115OtherGROUP PTAN
260029980OtherRR MED
VAC06115OtherGROUP PTAN