Provider Demographics
NPI:1568450138
Name:MISARE, BRUCE DONALD (MD, RPH)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DONALD
Last Name:MISARE
Suffix:
Gender:M
Credentials:MD, RPH
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:DONALD
Other - Last Name:MISARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, RPH
Mailing Address - Street 1:907 MESSARA DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-6074
Mailing Address - Country:US
Mailing Address - Phone:970-482-2476
Mailing Address - Fax:
Practice Address - Street 1:907 MESSARA DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-6074
Practice Address - Country:US
Practice Address - Phone:970-482-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2017-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11674183500000X
WI66343-2202086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G24576Medicare UPIN
508818Medicare ID - Type Unspecified
508818Medicare ID - Type Unspecified