Provider Demographics
NPI:1881762649
Name:ISAACSON, BRUCE A (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:ISAACSON
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 1:550 E 1400 N STE Z
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2407
Mailing Address - Country:US
Mailing Address - Phone:435-755-5799
Mailing Address - Fax:435-755-5839
Practice Address - Street 1:550 E 1400 N STE Z
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2407
Practice Address - Country:US
Practice Address - Phone:435-755-5799
Practice Address - Fax:435-755-5839
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178069-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE45932Medicare UPIN