Provider Demographics
NPI:1619931979
Name:FREE, BRUCE A (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:FREE
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 1:10201 SE MAIN ST
Mailing Address - Street 2:SUITE 29
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2937
Mailing Address - Country:US
Mailing Address - Phone:503-251-6363
Mailing Address - Fax:503-251-6239
Practice Address - Street 1:10201 SE MAIN ST
Practice Address - Street 2:SUITE 29
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2937
Practice Address - Country:US
Practice Address - Phone:503-251-6363
Practice Address - Fax:503-251-6239
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO11383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0186932OtherWA LABOR & INDUSTRIES
OR123356Medicaid
OR123356Medicaid
WA0186932OtherWA LABOR & INDUSTRIES