Healthcare Provider Details

I. General information

NPI: 1245235001
Provider Name (Legal Business Name): BRUCE MICHAEL DISTELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3186 VILLAGE DR STE 201
FAYETTEVILLE NC
28304-3979
US

IV. Provider business mailing address

3186 VILLAGE DR 201
FAYETTEVILLE NC
28304-3979
US

V. Phone/Fax

Practice location:
  • Phone: 910-486-5700
  • Fax: 910-486-5950
Mailing address:
  • Phone: 910-486-5700
  • Fax: 910-486-5950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number33497
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: