Healthcare Provider Details

I. General information

NPI: 1205890530
Provider Name (Legal Business Name): WILLIAM BRUCE ETHRIDGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 W 25TH STREET STE F
YUMA AZ
85364
US

IV. Provider business mailing address

PO BOX 2332
PALM SPRINGS CA
92263
US

V. Phone/Fax

Practice location:
  • Phone: 928-314-1174
  • Fax: 928-314-1175
Mailing address:
  • Phone: 760-322-1205
  • Fax: 760-778-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number12956
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number12956
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: