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General NPI Number Information
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NPI Number | 1508855917
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Entity Type | Individual
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Provider Name | BRUCE E. GOLLUB M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/18/2005
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Last Update Date | 11/30/2023
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Provider Practice Location Address
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Address Line | 775 POLE LINE RD W STE 103
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City | TWIN FALLS
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State | ID
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Zip | 83301-5819
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Country | US
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Telephone | 208-814-8375
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Fax | 208-814-8376
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Provider Business Mailing Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 80-158
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 80-158
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M-17332
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License Number State | ID
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