Healthcare Provider Details

I. General information

NPI: 1407814858
Provider Name (Legal Business Name): BRUCE C WASHINGTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD SUITE 102
DEARBORN MI
48124-5032
US

IV. Provider business mailing address

1420 STEPHENSON HWY SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-5533
  • Fax: 313-982-5508
Mailing address:
  • Phone: 248-581-5974
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301039685
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301039685
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: