Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | J4011 | TX |
Y | 2080P0204X | Pediatric Emergency Doctor | J4011 | TX |
NPI | 1295711901 |
---|---|
Provider Name | Gordon Bruce |
First Address | Dallas, TX 75266-0599 |
Second Address | Dallas, TX 75204-6109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2005 |
Last Update Date | 15/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
113281304 | (05) | TX |
113281305 | (05) | TX |
113281306 | (05) | TX |
113281307 | (05) | TX |
113281308 | (05) | TX |
113281309 | (05) | TX |
113281310 | (05) | TX |
113281311 | (05) | TX |
113281312 | (05) | TX |
113281313 | (05) | TX |
G17779 | (02) | TX |