Provider Demographics
NPI:1336119312
Name:SMITH, BRUCE MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:MICHAEL
Last Name:SMITH
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 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3404
Mailing Address - Country:US
Mailing Address - Phone:970-484-6373
Mailing Address - Fax:970-484-0382
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:SUITE 350
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3404
Practice Address - Country:US
Practice Address - Phone:970-484-6373
Practice Address - Fax:970-484-0382
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2020-11-05
Deactivation Date:2020-06-02
Deactivation Code:
Reactivation Date:2020-11-05
Provider Licenses
StateLicense IDTaxonomies
CO22552207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22552OtherCOLORADO LICENSE #
WY107665500Medicaid
WY2913AOtherWYO. LICENSE #
CO01225523Medicaid
WY2913AOtherWYO. LICENSE #
CO22552OtherCOLORADO LICENSE #