Provider Demographics
NPI:1477761625
Name:BRUCE S. WEST
Entity Type:Organization
Organization Name:BRUCE S. WEST
Other - Org Name:BRUCE S. WEST, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-261-7707
Mailing Address - Street 1:1340 S 18TH ST
Mailing Address - Street 2:STE. 203
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4799
Mailing Address - Country:US
Mailing Address - Phone:904-261-7707
Mailing Address - Fax:904-261-8616
Practice Address - Street 1:1340 S 18TH ST
Practice Address - Street 2:STE. 203
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4799
Practice Address - Country:US
Practice Address - Phone:904-261-7707
Practice Address - Fax:904-261-8616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042844261QH0100X
FLME99878261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006734952Medicaid
GA113328677AMedicaid
FL280146900Medicaid
FL280146900Medicaid