Provider Demographics
NPI:1407894173
Name:LIDSTON, BRUCE MALCOM (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:MALCOM
Last Name:LIDSTON
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 1:7297 LOVELAND DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-4562
Mailing Address - Country:US
Mailing Address - Phone:814-643-0766
Mailing Address - Fax:
Practice Address - Street 1:1227 WARM SPRINGS AVE
Practice Address - Street 2:J.C. BLAIR PHYSICIAN'S BUILDING #301
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2300
Practice Address - Country:US
Practice Address - Phone:814-643-0531
Practice Address - Fax:814-643-6637
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016074E2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000676816/0004Medicaid
PA000676816/0004Medicaid