Provider Demographics
NPI:1205890530
Name:ETHRIDGE, WILLIAM BRUCE (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRUCE
Last Name:ETHRIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2332
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92263
Mailing Address - Country:US
Mailing Address - Phone:760-322-1205
Mailing Address - Fax:760-778-5770
Practice Address - Street 1:1951 W 25TH STREET
Practice Address - Street 2:STE F
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364
Practice Address - Country:US
Practice Address - Phone:928-314-1174
Practice Address - Fax:928-314-1175
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ129562085R0001X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ249145OtherAHCCCS
AZ249145OtherAHCCCS
AZE00268Medicare UPIN
Z113017Medicare PIN