Provider Demographics
NPI:1649381351
Name:BRUCE, MARK D (D O)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BRUCE
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2315
Mailing Address - Country:US
Mailing Address - Phone:414-877-5350
Mailing Address - Fax:414-877-5360
Practice Address - Street 1:19333 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4132
Practice Address - Country:US
Practice Address - Phone:262-785-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25131207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32658800Medicaid
WI391204982014OtherBLUE CROSS GROUP
WI30019300Medicaid
WI001868500Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
WI391204982014OtherBLUE CROSS GROUP
WIB51793Medicare UPIN