Healthcare Provider Details

I. General information

NPI: 1306186275
Provider Name (Legal Business Name): BRUCE C TWADDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 MONTLAKE BLVD ROOM 148B
SEATTLE WA
98195-0007
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-1552
  • Fax: 206-543-6573
Mailing address:
  • Phone: 206-543-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberTR60365934
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: