Healthcare Provider Details

I. General information

NPI: 1588632780
Provider Name (Legal Business Name): BRUCE STEWART WEST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S 18TH ST #203
FERNANDINA BEACH FL
32034-4799
US

IV. Provider business mailing address

1340 S 18TH ST #203
FERNANDINA BEACH FL
32034-4799
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-7707
  • Fax: 907-261-8616
Mailing address:
  • Phone: 904-261-7707
  • Fax: 907-261-8616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101042844
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME99878
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: