Provider Demographics
NPI:1265920326
Name:BRUE, TREVOR TODD (DO)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:TODD
Last Name:BRUE
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 1:310 W LOSEY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5250
Mailing Address - Country:US
Mailing Address - Phone:618-256-9355
Mailing Address - Fax:
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X
MO2021018193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program