Provider Demographics
NPI:1578568317
Name:DRAGOO, BRUCE DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DOUGLAS
Last Name:DRAGOO
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 1:1000 EAST PARIS SE
Mailing Address - Street 2:STE 225
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-957-3643
Mailing Address - Fax:616-957-0896
Practice Address - Street 1:1000 EAST PARIS SE
Practice Address - Street 2:STE 225
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-957-3643
Practice Address - Fax:616-957-0896
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-03-11
Deactivation Date:2020-06-03
Deactivation Code:
Reactivation Date:2021-03-11
Provider Licenses
StateLicense IDTaxonomies
MI4301028716207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1083311Medicaid
MI4301028716OtherMI STATE LICENSE
MI180D117670OtherBLUE CROSS & BLUE SHIELD
MI382237488OtherPRIORITY HEALTH
MIBD028716OtherMI BCBS STAT LICENSE