Provider Demographics
NPI:1619269099
Name:KINNEY, BRUCE S (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:S
Last Name:KINNEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 W CAMP WISDOM RD STE 170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-2643
Mailing Address - Country:US
Mailing Address - Phone:972-942-7700
Mailing Address - Fax:972-942-7701
Practice Address - Street 1:3107 W CAMP WISDOM RD STE 170
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2643
Practice Address - Country:US
Practice Address - Phone:972-942-7700
Practice Address - Fax:972-942-7701
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6008207Q00000X
HIDOS 1731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338946202Medicaid
TX338946201Medicaid
TX363190YLPSOtherWELLMED PTAN