Provider Demographics
NPI:1700848769
Name:LAVERTY, BRUCE R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:LAVERTY
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:PO BOX 788250
Mailing Address - Street 2:MARINE CORPS AIR GROUND COMBAT CENTER
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278-8250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MARINE CORPS AIR GROUND COMBAT CENTER
Practice Address - Street 2:BOX 788250
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8250
Practice Address - Country:US
Practice Address - Phone:760-830-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG66108207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology