Provider Demographics
NPI:1609960699
Name:ANDERSEN, BRUCE A (DPM)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701
Mailing Address - Country:US
Mailing Address - Phone:505-425-9491
Mailing Address - Fax:505-454-8171
Practice Address - Street 1:109 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701
Practice Address - Country:US
Practice Address - Phone:505-425-9491
Practice Address - Fax:505-454-8171
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM163213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
005351OtherBCBS
10478OtherPRESBYTERIAN HP
005351OtherBCBS
NM2350673Medicare PIN