Provider Demographics
NPI:1033292461
Name:RAYBURN, BRUCE EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDWARD
Last Name:RAYBURN
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 1:390 GRIFFITH ST
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360
Mailing Address - Country:US
Mailing Address - Phone:318-443-6323
Mailing Address - Fax:318-443-6189
Practice Address - Street 1:390 GRIFFITH ST
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360
Practice Address - Country:US
Practice Address - Phone:318-493-6323
Practice Address - Fax:318-443-6189
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018519208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1911895Medicaid
E77957Medicare UPIN
LA5N455Medicare ID - Type Unspecified