Provider Demographics
NPI:1043390974
Name:MARTIN, BRUCE D (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
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 1:12461 TIMBERLAND BLVD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-741-5437
Mailing Address - Fax:888-400-5412
Practice Address - Street 1:12461 TIMBERLAND BLVD
Practice Address - Street 2:SUITE 309
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5213
Practice Address - Country:US
Practice Address - Phone:817-741-5437
Practice Address - Fax:817-977-5439
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8824208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U87ZOtherBCBSTX GRP PIN
TX165586203Medicaid
TXMARBI09084OtherCCHIP PIN
TX8A5662OtherBCBSTX PIN
TX2619123OtherUHC PIN
TX1881820595OtherGROUP NPI NUMBER
TX7340635OtherAETNA PIN
TX205573301Medicaid
TX8BQ027OtherBCBS
TX8A5662OtherBCBSTX PIN