Healthcare Provider Details

I. General information

NPI: 1558824797
Provider Name (Legal Business Name): JOHN-DAVID CONSTANTINE BRUCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 05/17/2025
Certification Date: 05/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DUGAS BUILDING (BG-1071) 1120 15TH STREET
AUGUSTA GA
30912-0001
US

IV. Provider business mailing address

811 BRYNWOOD DR
CHATTANOOGA TN
37415-3303
US

V. Phone/Fax

Practice location:
  • Phone: 706-621-9442
  • Fax:
Mailing address:
  • Phone: 423-432-7976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberV8591
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10829
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: