Provider Demographics
NPI:1336238336
Name:FAWCETT, BRUCE G (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:G
Last Name:FAWCETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1514 GLENWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2368
Mailing Address - Country:US
Mailing Address - Phone:919-829-0076
Mailing Address - Fax:919-836-9094
Practice Address - Street 1:1514 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-2368
Practice Address - Country:US
Practice Address - Phone:919-829-0076
Practice Address - Fax:919-836-9094
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC154213E00000X, 213EP0504X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2751610OtherUNITED
NC08064OtherBCBS
NC1115086015OtherCIGNA
NC480017899OtherRAILROAD MEDICARE
NC7908064Medicaid
NC16437OtherPARTNERS
NC561412156OtherHUMANA
NC4279205OtherAETNA
NC440912OtherOPTIMUM CHOICE
NC7908064Medicaid
NCNCR563F491Medicare PIN
NC7908064Medicaid