Provider Demographics
NPI:1881652444
Name:VAN NATTA, BRUCE W (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
Last Name:VAN NATTA
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 1:170 W 106TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1004
Mailing Address - Country:US
Mailing Address - Phone:317-575-0330
Mailing Address - Fax:317-846-5719
Practice Address - Street 1:170 W 106TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1004
Practice Address - Country:US
Practice Address - Phone:317-575-0330
Practice Address - Fax:317-846-5719
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031291A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN117890BMedicare ID - Type Unspecified
IND94532Medicare UPIN