Provider Demographics
NPI:1689781643
Name:STOCKHOUSE, BRUCE C (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:STOCKHOUSE
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 1:4501 DIPLOMACY DR
Mailing Address - Street 2:ATTN: FINANCE/PROVIDER ENROLLMENT
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5919
Mailing Address - Country:US
Mailing Address - Phone:907-729-3300
Mailing Address - Fax:
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-563-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0671Medicaid
AK8EZ94GMedicare ID - Type Unspecified
AKF09937Medicare UPIN