Provider Demographics
NPI:1598848053
Name:MACDONALD, BRUCE D (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:MACDONALD
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 1:36261 WASHINGTON LOOP RD.
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33982
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36261 WASHINGTON LOOP RD.
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33982
Practice Address - Country:US
Practice Address - Phone:941-639-7568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 213292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61536Medicare UPIN
080524Medicare ID - Type Unspecified