Provider Demographics
NPI:1366446734
Name:JONES, BRUCE (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:JONES
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 1:40 N KINGS HWY
Mailing Address - Street 2:APT 15J
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1333
Mailing Address - Country:US
Mailing Address - Phone:314-361-2822
Mailing Address - Fax:
Practice Address - Street 1:129 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EAST ST LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2917
Practice Address - Country:US
Practice Address - Phone:618-482-7242
Practice Address - Fax:314-810-1399
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK12737/818070Medicare ID - Type UnspecifiedMEDICARE #/GROUP #