Provider Demographics
NPI:1336181593
Name:HIGINBOTHOM, BRUCE CARTER (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CARTER
Last Name:HIGINBOTHOM
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 1:445 PORTERFIELD HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210
Mailing Address - Country:US
Mailing Address - Phone:276-628-3144
Mailing Address - Fax:276-628-1571
Practice Address - Street 1:445 PORTERFIELD HWY
Practice Address - Street 2:SUITE A
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210
Practice Address - Country:US
Practice Address - Phone:276-628-3144
Practice Address - Fax:276-628-1571
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005605008Medicaid
VA007610432Medicaid
VACO6336Medicare PIN
VAG34736Medicare UPIN
VA080007316Medicare PIN
VA005605008Medicaid