Provider Demographics
NPI:1659308617
Name:GARRETSON, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
Last Name:GARRETSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39650 ORCHARD HILL PL
Mailing Address - Street 2:200
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5391
Mailing Address - Country:US
Mailing Address - Phone:248-319-0161
Mailing Address - Fax:248-319-0170
Practice Address - Street 1:3555 W 13 MILE RD
Practice Address - Street 2:LL-20
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-288-2280
Practice Address - Fax:248-288-5644
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301402686207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M21980007Medicare PIN
C41326Medicare UPIN
MI1659308617Medicaid
MI0Q26082015Medicare PIN
MI4879915Medicaid
381946761OtherGROUP TAX ID #
0Q26082015Medicare ID - Type Unspecified
MI3018528Medicaid
MI3457911Medicaid
MI0Q26082015Medicare PIN