Provider Demographics
NPI:1558302125
Name:BRUYA, TIMOTHY E (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:BRUYA
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 1:104 W 5TH
Mailing Address - Street 2:#400 WEST
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204
Mailing Address - Country:US
Mailing Address - Phone:509-353-3960
Mailing Address - Fax:509-343-0134
Practice Address - Street 1:104 W 5TH
Practice Address - Street 2:#400 WEST
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-353-3960
Practice Address - Fax:509-343-0134
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000173831744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744R1102XOther Service ProvidersSpecialistResearch Study
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8145203Medicaid
B002OtherTRI CARE
WABR5756OtherASURIS
WA130579OtherL&I
MT0024765Medicaid
B002OtherTRI CARE