Provider Demographics
NPI:1528030418
Name:MADDERN, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
Last Name:MADDERN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1033 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:STE. 108
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1547
Mailing Address - Country:US
Mailing Address - Phone:727-456-4250
Mailing Address - Fax:727-346-1044
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 302
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5003
Practice Address - Country:US
Practice Address - Phone:904-398-5437
Practice Address - Fax:904-398-3077
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2014-06-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0056292207YP0228X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0205114006OtherCIGNA
FL2218700OtherAETNA
FL061886100Medicaid
FLP2759499OtherOXFORD
FL08675OtherBCBS
FL12056336OtherMULTIPLAN
FL203211OtherAV MED
FL08675OtherBCBS