Provider Demographics
NPI:1821042441
Name:WHITE, BRUCE DAVID (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DAVID
Last Name:WHITE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N CENTRAL AVE
Mailing Address - Street 2:ST. 900
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2425
Mailing Address - Country:US
Mailing Address - Phone:602-406-3729
Mailing Address - Fax:602-798-9412
Practice Address - Street 1:124 W THOMAS RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4405
Practice Address - Country:US
Practice Address - Phone:602-406-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ852261Medicaid
AZBW0589599OtherDEA NUMBER
AZBW0589599OtherDEA NUMBER
AZF12251Medicare UPIN