Provider Demographics
NPI:1538108758
Name:PETERS, BRUCE B (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:B
Last Name:PETERS
Suffix:
Gender:M
Credentials:DO
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 10549
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0549
Mailing Address - Country:US
Mailing Address - Phone:727-824-8181
Mailing Address - Fax:727-824-8134
Practice Address - Street 1:707 DRUID RD E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3913
Practice Address - Country:US
Practice Address - Phone:727-824-8181
Practice Address - Fax:727-443-7230
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10661207RA0401X, 208000000X
MODO 110214208000000X
NY242970208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001203800Medicaid
MO248476020Medicaid
NY248476038Medicaid
D16535Medicare UPIN
FLBX362ZMedicare Oscar/Certification
NY248476038Medicaid