Healthcare Provider Details

I. General information

NPI: 1720204555
Provider Name (Legal Business Name): BRUCE ALLEN GUBERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 6TH AVE
HUNTINGTON WV
25701-2104
US

IV. Provider business mailing address

612 6TH AVE
HUNTINGTON WV
25701-2104
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-4202
  • Fax: 304-525-4231
Mailing address:
  • Phone: 304-525-4202
  • Fax: 304-525-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number13133
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number21964
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number2005012335
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number35037538R
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: