Provider Demographics
NPI:1912999608
Name:CHAMPAGNE, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:CHAMPAGNE
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 1:2101 CENTRE PARK WEST DR STE 175
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-6466
Mailing Address - Country:US
Mailing Address - Phone:561-242-3009
Mailing Address - Fax:
Practice Address - Street 1:2101 CENTREPARK WEST DR.
Practice Address - Street 2:SUITE 175
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409
Practice Address - Country:UM
Practice Address - Phone:561-242-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL119752207R00000X
NY175085207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01911848Medicaid
NY005AE1Medicare ID - Type Unspecified
F15085Medicare UPIN