Provider Demographics
NPI:1588632780
Name:WEST, BRUCE STEWART (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:STEWART
Last Name:WEST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1340 S 18TH ST
Mailing Address - Street 2:#203
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4799
Mailing Address - Country:US
Mailing Address - Phone:904-261-7707
Mailing Address - Fax:907-261-8616
Practice Address - Street 1:1340 S 18TH ST
Practice Address - Street 2:#203
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4799
Practice Address - Country:US
Practice Address - Phone:904-261-7707
Practice Address - Fax:907-261-8616
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101042844208000000X
FLME99878208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280146900Medicaid
VA6734952Medicaid
VA6734952Medicaid