Provider Demographics
NPI:1083719504
Name:MASSAU, BRUCE (DO A PROF)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MASSAU
Suffix:
Gender:M
Credentials:DO A PROF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E TOWN ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4741
Mailing Address - Country:US
Mailing Address - Phone:614-252-1500
Mailing Address - Fax:614-252-1685
Practice Address - Street 1:393 E TOWN ST
Practice Address - Street 2:SUITE 109
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4741
Practice Address - Country:US
Practice Address - Phone:614-252-1500
Practice Address - Fax:614-252-1685
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003227208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0472662Medicaid
OH0498674Medicare PIN
OHC02135Medicare UPIN