Provider Demographics
NPI:1710049945
Name:SMITH, BRUCE ELLIOTT (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ELLIOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 HIBISCUS DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6142
Mailing Address - Country:US
Mailing Address - Phone:909-383-3057
Mailing Address - Fax:909-383-3212
Practice Address - Street 1:799 E RIALTO AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0011
Practice Address - Country:US
Practice Address - Phone:909-383-3057
Practice Address - Fax:909-383-3212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG069218207Q00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC21971Medicare UPIN