Provider Demographics
NPI:1114300795
Name:BRUCE E WHITEHEAD, MD, PA
Entity Type:Organization
Organization Name:BRUCE E WHITEHEAD, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IVELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-294-8989
Mailing Address - Street 1:12201 MERIT DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2213
Mailing Address - Country:US
Mailing Address - Phone:214-294-8989
Mailing Address - Fax:214-294-8977
Practice Address - Street 1:12201 MERIT DR
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2213
Practice Address - Country:US
Practice Address - Phone:214-294-8989
Practice Address - Fax:214-294-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX397445Medicare UPIN