Provider Demographics
NPI:1790923969
Name:WHITAKER, BRUCE LEE JR (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:WHITAKER
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-854-6008
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-7745
Practice Address - Fax:706-774-5789
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101016483207R00000X, 207RC0200X
LA062124207RC0200X
IDOC-0415207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E00425OtherBLUE CROSS BLUE SHIELD
MI1790923969Medicaid
MI0F34972Medicare PIN