Provider Demographics
NPI:1629040407
Name:TEMPEST, BRUCE D (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:TEMPEST
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 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:650 VANDEN BOSCH PKWY
Practice Address - Street 2:#A
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5508
Practice Address - Country:US
Practice Address - Phone:505-726-6980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM70-208207Q00000X, 207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102935Medicaid
NM10017955OtherLOVELACE
NMNM001H34OtherBCBS
NMS0884Medicaid
NMPROVP15878OtherMOLINA
NM10017955OtherLOVELACE