Provider Demographics
NPI:1619974946
Name:HARTWIG, BRUCE ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLAN
Last Name:HARTWIG
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 1:3 SHIRCLIFF WAY STE 752
Mailing Address - Street 2:SUITE 752
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4786
Mailing Address - Country:US
Mailing Address - Phone:904-389-6226
Mailing Address - Fax:904-388-7265
Practice Address - Street 1:3 SHIRCLIFF WAY STE 752
Practice Address - Street 2:SUITE 752
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4786
Practice Address - Country:US
Practice Address - Phone:904-389-6226
Practice Address - Fax:904-388-7265
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00393172084N0400X
FLME0039320002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0623807OtherAETNA INS PROVIDER NUMBER
FL592157126OtherTRICARE, UNITED HEALTHCAR
FL130000461OtherRAILROAD MEDICARE NUMBER
FL40188OtherAV-MED PROVIDER NUMBER
FL130000461OtherRAILROAD MEDICARE NUMBER
FL10966Medicare ID - Type UnspecifiedMEDICARE PROVIDER