Provider Demographics
NPI:1356348338
Name:PACKER, BRUCE PAUL (MD)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:PAUL
Last Name:PACKER
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 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:928-710-0099
Mailing Address - Fax:928-443-1001
Practice Address - Street 1:2929 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-8034
Practice Address - Country:US
Practice Address - Phone:928-710-0099
Practice Address - Fax:928-443-1001
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22007207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860919517OtherTIN #
AZZ24632Medicare PIN
F79308Medicare UPIN