Provider Demographics
NPI:1639134901
Name:ENNIS, BRUCE MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MARTIN
Last Name:ENNIS
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 1:675 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-4600
Mailing Address - Country:US
Mailing Address - Phone:985-200-3530
Mailing Address - Fax:985-202-2010
Practice Address - Street 1:675 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-4600
Practice Address - Country:US
Practice Address - Phone:985-200-3530
Practice Address - Fax:985-202-2010
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201758207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA31725ZYJTOtherMEDICARE
LA1973025Medicaid
LA2432401Medicaid
LA31725ZYJTOtherMEDICARE
LA4P581Medicare PIN