Provider Demographics
NPI:1184779183
Name:MATTE, BRUCE MICHAEL (PD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MICHAEL
Last Name:MATTE
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 17
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:LA
Mailing Address - Zip Code:71260-0017
Mailing Address - Country:US
Mailing Address - Phone:318-292-4634
Mailing Address - Fax:
Practice Address - Street 1:314 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:LA
Practice Address - Zip Code:71260
Practice Address - Country:US
Practice Address - Phone:318-292-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1063447787Medicare NSC