Provider Demographics
NPI:1356307433
Name:SCHULTZ, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:SCHULTZ
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 742712
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2712
Mailing Address - Country:US
Mailing Address - Phone:877-866-7123
Mailing Address - Fax:
Practice Address - Street 1:17218 PRESTON RD STE 2000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-4018
Practice Address - Country:US
Practice Address - Phone:954-399-4673
Practice Address - Fax:309-543-2089
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110300207Q00000X
TXU0534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX457535901Medicaid
ILG59887Medicare UPIN
IL036110300Medicaid