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NPI Code Detail

MEDICARE: JOHN BRUCE ADDISON D.O.

MEDICARE: JOHN BRUCE ADDISON D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianJ1829TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1J1829OTHERTXLICENSE

General Provider Information

NPI Number : 1629094552
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN BRUCE ADDISON D.O.
Provider Business Mailing Address
First Line : 997 W INTERSTATE 20
Second Line :
City : COLORADO CITY
State : TX
Zip : 79512-3998
Country : US
Telephone Number : 325-728-2693
Fax Number : 325-728-2420
Provider Business Practice Location Address
First Line : 997 W INTERSTATE 20
Second Line :
City : COLORADO CITY
State : TX
Zip : 79512-2685
Country : US
Telephone Number : 325-728-2693
Fax Number : 325-728-2420
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/14/2006
Last Update Date : 03/07/2023

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