Provider Demographics
NPI:1114060308
Name:BRUCE, DIANE (OD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BRUCE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 LAUREL TER
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:198 SW BROAD ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1101
Practice Address - Country:US
Practice Address - Phone:912-530-6000
Practice Address - Fax:912-530-6044
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001278152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA814827714EMedicaid
GA41ZCFQHMedicare ID - Type Unspecified
GAU52643Medicare UPIN