Provider Demographics
NPI:1548324254
Name:BRUCE, TAMI R (MD)
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:R
Last Name:BRUCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3638 E SOUTHERN AVE
Mailing Address - Street 2:STE C108
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2563
Mailing Address - Country:US
Mailing Address - Phone:480-834-0771
Mailing Address - Fax:480-834-1136
Practice Address - Street 1:3638 E SOUTHERN AVE
Practice Address - Street 2:STE C108
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2563
Practice Address - Country:US
Practice Address - Phone:480-834-0771
Practice Address - Fax:480-834-1136
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26874207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ688195Medicaid
AZZWCGCDMedicare PIN
AZ688195Medicaid