Provider Demographics
NPI:1780615583
Name:DAVISON, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:DAVISON
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 1:5499 STATE ROAD 167
Mailing Address - Street 2:
Mailing Address - City:HUBERTUS
Mailing Address - State:WI
Mailing Address - Zip Code:53033-9773
Mailing Address - Country:US
Mailing Address - Phone:812-344-4201
Mailing Address - Fax:
Practice Address - Street 1:4855 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-432-7599
Practice Address - Fax:262-432-7694
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1036816208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100358660Medicaid
IN000000984523OtherANTHEM PIN