Provider Demographics
NPI:1558355578
Name:CRAIG, BRUCE L (MD FAAFP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:CRAIG
Suffix:
Gender:M
Credentials:MD FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 RED OAK LOOP
Mailing Address - Street 2:
Mailing Address - City:POLLOCK
Mailing Address - State:LA
Mailing Address - Zip Code:71467-4341
Mailing Address - Country:US
Mailing Address - Phone:318-765-9020
Mailing Address - Fax:
Practice Address - Street 1:3819 PATTERSON ST
Practice Address - Street 2:
Practice Address - City:POLLOCK
Practice Address - State:LA
Practice Address - Zip Code:71467
Practice Address - Country:US
Practice Address - Phone:318-765-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1162736Medicaid
010051840OtherRAILROAD MEDICARE
010051840OtherRAILROAD MEDICARE
LA1162736Medicaid