Provider Demographics
NPI:1285670950
Name:MAST, BRUCE ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:MAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-271-5367
Mailing Address - Fax:352-271-5385
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-271-5367
Practice Address - Fax:352-271-5385
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377560700Medicaid
FLCI6613OtherRAILROAD MEDIARE
FL68747OtherBCBS FL
FL377560700Medicaid
FLCI6613OtherRAILROAD MEDIARE
FLG05462Medicare UPIN