Provider Demographics
NPI:1477509743
Name:KNOX, BRUCE R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:KNOX
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 1:3114 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8338
Mailing Address - Country:US
Mailing Address - Phone:337-562-0696
Mailing Address - Fax:337-474-1378
Practice Address - Street 1:3114 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8338
Practice Address - Country:US
Practice Address - Phone:337-562-0696
Practice Address - Fax:337-474-1378
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09838R2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR243024Medicaid
MS05583595Medicaid
LA1972053Medicaid
LAF45489Medicare UPIN
MS300000909Medicare PIN
MS05583595Medicaid
LA1972053Medicaid