Provider Demographics
NPI:1396769220
Name:BRUDER, WALLACE JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:JOHN
Last Name:BRUDER
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 1:4045 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8965
Mailing Address - Country:US
Mailing Address - Phone:231-935-0900
Mailing Address - Fax:231-935-0308
Practice Address - Street 1:4045 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8965
Practice Address - Country:US
Practice Address - Phone:231-935-0900
Practice Address - Fax:231-935-0308
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033897207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103104985Medicaid
MIA77100Medicare UPIN
MI103104985Medicaid