Provider Demographics
NPI:1174512057
Name:PROVIDENCE, BERTRAM CLIFFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:CLIFFORD
Last Name:PROVIDENCE
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:HQ 2ID ATTN: DSO
Mailing Address - Street 2:UNIT 15041
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96258
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDCOM
Practice Address - Street 2:ATTN: DCCS-QM (CREDENTIALS)
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205-0054
Practice Address - Country:KR
Practice Address - Phone:0118227-916-6027
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-11256207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery