Provider Demographics
NPI:1265655237
Name:ESPENSHADE, BRUCE M (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:ESPENSHADE
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-6399
Practice Address - Fax:707-967-5915
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42342207P00000X, 207Q00000X
CAC139297208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201140380Medicaid
KY7100068760Medicaid
KY000000601798OtherBCBS
KYK042110OtherMEDICARE- NORTON HEALTHCARE
KY000000759205OtherANTHEM-NICC
IN201140380Medicaid