Provider Demographics
NPI:1801836788
Name:BOLLINGER, BRUCE ALAN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:BOLLINGER
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 1:800 12TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2518
Mailing Address - Country:US
Mailing Address - Phone:817-877-1118
Mailing Address - Fax:
Practice Address - Street 1:800 12TH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2519
Practice Address - Country:US
Practice Address - Phone:817-877-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1468174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPOOOB02ROMedicaid
TXPOOOB02ROMedicaid
TXOOB02RMedicare PIN
TX200005389Medicare PIN