Provider Demographics
NPI:1639210743
Name:ALLEN, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:ALLEN
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-2370
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1025 SAINT JOSEPH LN
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8345
Practice Address - Country:US
Practice Address - Phone:606-330-2370
Practice Address - Fax:606-877-1593
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30889208600000X, 208G00000X
KY55522208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30889OtherLICENSE
KY55522OtherKY MEDICAL LICENSE
CAYYY34803YMedicaid
CAA44584Medicare UPIN