Provider Demographics
NPI:1790754273
Name:HOLMES, BRUCE NEAL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:NEAL
Last Name:HOLMES
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 1:19875 SW 65TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8353
Mailing Address - Country:US
Mailing Address - Phone:503-692-7785
Mailing Address - Fax:503-885-9882
Practice Address - Street 1:19875 SW 65TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8353
Practice Address - Country:US
Practice Address - Phone:503-692-7785
Practice Address - Fax:503-885-9882
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR19222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8289571Medicaid
OR073291Medicaid
OR110302Medicare PIN
OR073291Medicaid