Provider Demographics
NPI:1518047588
Name:SMITH, BRUCE D (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:SMITH
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:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-635-2562
Mailing Address - Fax:307-432-2676
Practice Address - Street 1:4017 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-635-2562
Practice Address - Fax:307-432-2676
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6931A207XX0005X
NE20195207XX0005X
SD1724207XX0005X
IA27005207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1185322 00Medicaid
WYP00048676OtherRAIL ROAD MEDICARE
WY312201OtherBLUE CROSS BLUE SHIELD
WY9727Medicare ID - Type Unspecified
WY1185322 00Medicaid