Provider Demographics
NPI:1952393159
Name:BRINK, BRUCE CARLTON (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CARLTON
Last Name:BRINK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-1516
Mailing Address - Country:US
Mailing Address - Phone:812-386-7522
Mailing Address - Fax:812-386-1097
Practice Address - Street 1:410 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1516
Practice Address - Country:US
Practice Address - Phone:812-386-7522
Practice Address - Fax:812-386-1097
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000104A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1004717110AMedicaid
IN1004717110AMedicaid
E45841Medicare UPIN