Provider Demographics
NPI:1497783955
Name:ANDERSON, BRUCE JOHN (MD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:JOHN
Last Name:ANDERSON
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 1:2724 ISLE ROYALE CT
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-3424
Mailing Address - Country:US
Mailing Address - Phone:952-707-6781
Mailing Address - Fax:
Practice Address - Street 1:2724 ISLE ROYALE CT
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-3424
Practice Address - Country:US
Practice Address - Phone:952-707-6781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND81220Medicare UPIN