Provider Demographics
NPI:1023012366
Name:MARTIN, BRUCE W (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:MARTIN
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 1:3101 SUMMIT VIEW DR.
Mailing Address - Street 2:
Mailing Address - City:DACONO
Mailing Address - State:CO
Mailing Address - Zip Code:80514
Mailing Address - Country:US
Mailing Address - Phone:303-925-4150
Mailing Address - Fax:303-925-4152
Practice Address - Street 1:3101 SUMMIT VIEW DR.
Practice Address - Street 2:
Practice Address - City:DACONO
Practice Address - State:CO
Practice Address - Zip Code:80514
Practice Address - Country:US
Practice Address - Phone:303-925-4150
Practice Address - Fax:303-925-4152
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044691207Q00000X
CO54105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3107987Medicaid
MIM74460209Medicare PIN
MI0M08610004Medicare ID - Type Unspecified
D90162Medicare UPIN