Provider Demographics
NPI:1770578882
Name:WALLSTEDT, BRUCE A (MD)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:A
Last Name:WALLSTEDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6323 CANTERBURY CLOSE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4870
Mailing Address - Country:US
Mailing Address - Phone:615-504-9479
Mailing Address - Fax:615-730-7334
Practice Address - Street 1:6323 CANTERBURY CLOSE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4870
Practice Address - Country:US
Practice Address - Phone:615-504-9479
Practice Address - Fax:615-730-7334
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2010-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNMD25914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3086317Medicaid
TNF91716Medicare UPIN
TN3086317Medicaid