Provider Demographics
NPI:1356447809
Name:BRUYN, JAMES MARK (DPM)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MARK
Last Name:BRUYN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 NORTH 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702
Mailing Address - Country:US
Mailing Address - Phone:409-833-7465
Mailing Address - Fax:409-833-7719
Practice Address - Street 1:450 NORTH 11TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702
Practice Address - Country:US
Practice Address - Phone:409-833-7465
Practice Address - Fax:409-833-7719
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0798213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120214506Medicaid
TX0538160001Medicare NSC
T12434Medicare UPIN
TX8C5983Medicare PIN