Healthcare Provider Details

I. General information

NPI: 1033268917
Provider Name (Legal Business Name): DEAN ELMER BRUCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1832 GEORGIA ST NE
ALBUQUERQUE NM
87110-5903
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-255-2978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA95036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: