Provider Demographics
NPI:1164466041
Name:BRUCE, DAVID RANDALL (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RANDALL
Last Name:BRUCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 COURT ST
Mailing Address - Street 2:SUITE #11
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2156
Mailing Address - Country:US
Mailing Address - Phone:209-223-0038
Mailing Address - Fax:209-223-0039
Practice Address - Street 1:817 COURT ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2156
Practice Address - Country:US
Practice Address - Phone:209-223-0038
Practice Address - Fax:209-223-0039
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5045207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E60345Medicare UPIN
020AS0450Medicare ID - Type Unspecified