Provider Demographics
NPI:1407814858
Name:WASHINGTON, BRUCE C (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-982-5533
Practice Address - Fax:313-982-5508
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-01-30
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Provider Licenses
StateLicense IDTaxonomies
MI4301039685208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104432256Medicaid
MIB47235Medicare UPIN
MI104432256Medicaid
MI0P30630563Medicare PIN