MEDICARE: BRUCE EDWARD WARDLAY 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
1	207Q00000X	Family Medicine Physician	G5748	TX

General Provider Information

NPI Number	:	1881810794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE EDWARD WARDLAY D.O.

Provider Business Mailing Address
First Line	:	1401 W JEFFERSON BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-5326
Country	:	US
Telephone Number	:	214-941-9200
Fax Number	:	214-941-9262

Provider Business Practice Location Address
First Line	:	1401 W JEFFERSON BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-5326
Country	:	US
Telephone Number	:	214-941-9200
Fax Number	:	214-941-9262

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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