Provider Demographics
NPI:1376505214
Name:DEPEW, BRUCE CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CRAIG
Last Name:DEPEW
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 1:2965 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3602
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:12391 S 4000 W
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7012
Practice Address - Country:US
Practice Address - Phone:801-302-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF42170Medicare UPIN
GA08BBSXDMedicare ID - Type Unspecified