Provider Demographics
NPI:1336139328
Name:BRUCE, WILLIE (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:
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 1:61 N. NELLIS BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110
Mailing Address - Country:US
Mailing Address - Phone:702-383-6240
Mailing Address - Fax:702-459-8586
Practice Address - Street 1:61 N. NELLIS BLVD.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110
Practice Address - Country:US
Practice Address - Phone:702-383-6240
Practice Address - Fax:702-459-8586
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-081683207P00000X
FLOS8626207P00000X
NVDO3108207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E77508Medicare UPIN