Provider Demographics
NPI:1629094552
Name:ADDISON, JOHN BRUCE (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRUCE
Last Name:ADDISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:
Other - Last Name:ADDISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:997 W INTERSTATE 20
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79512-3998
Mailing Address - Country:US
Mailing Address - Phone:325-728-2693
Mailing Address - Fax:325-728-2420
Practice Address - Street 1:997 W INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:COLORADO CITY
Practice Address - State:TX
Practice Address - Zip Code:79512-2685
Practice Address - Country:US
Practice Address - Phone:325-728-2693
Practice Address - Fax:325-728-2420
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1829207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ1829OtherLICENSE
TXJ1829OtherLICENSE