Provider Demographics
NPI:1780677930
Name:REID, BRUCE WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:WALTER
Last Name:REID
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 1:304 MARCELLA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2578
Mailing Address - Country:US
Mailing Address - Phone:757-864-0840
Mailing Address - Fax:757-864-0848
Practice Address - Street 1:304 MARCELLA RD
Practice Address - Street 2:SUITE B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2578
Practice Address - Country:US
Practice Address - Phone:757-864-0840
Practice Address - Fax:757-864-0848
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036538207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1780677930Medicaid
VAB04980Medicare UPIN