Provider Demographics
NPI:1336173863
Name:THOMAS, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:THOMAS
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 1:23343 NW COUNTY ROAD 236
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32643-9669
Mailing Address - Country:US
Mailing Address - Phone:386-454-0698
Mailing Address - Fax:386-454-0690
Practice Address - Street 1:1830 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:FL
Practice Address - Zip Code:32619-4713
Practice Address - Country:US
Practice Address - Phone:352-463-1100
Practice Address - Fax:352-463-4507
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0085069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0085069OtherMEDICAL LICENSE
FL26550800Medicaid
FL62987OtherBC
FL62987OtherBC
FLH75721Medicare UPIN
FL101937Medicare ID - Type UnspecifiedUGS MC
FL080184939Medicare ID - Type UnspecifiedRR MC