Provider Demographics
NPI:1851394530
Name:WAITE, BRUCE KEVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:KEVIN
Last Name:WAITE
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 1:404 W. FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2437
Mailing Address - Country:US
Mailing Address - Phone:507-373-2384
Mailing Address - Fax:507-668-2975
Practice Address - Street 1:1000 FIRST DR NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2941
Practice Address - Country:US
Practice Address - Phone:507-433-7351
Practice Address - Fax:507-668-2975
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO1972207V00000X
ORDO17052207V00000X
MN62771207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025226Medicaid
ORE99915Medicare UPIN
MEME2402Medicare PIN
MEME2402Medicare PIN