Provider Demographics
NPI:1558603969
Name:ALLEN, BRUCE STUART (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:STUART
Last Name:ALLEN
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 1:1338 OLD FORSYTH RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-7205
Mailing Address - Country:US
Mailing Address - Phone:478-471-7788
Mailing Address - Fax:
Practice Address - Street 1:1338 OLD FORSYTH RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-7205
Practice Address - Country:US
Practice Address - Phone:478-471-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-24
Last Update Date:2013-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20294207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20294OtherGEORGIA MEDICAL LICENCE NUMBER