Basic Information
| Provider Information | |||||||||
| NPI: | 1336173863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23343 NW COUNTY ROAD 236 | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326439669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864540698 | ||||||||
| FaxNumber: | 3864540690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1830 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326194713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524631100 | ||||||||
| FaxNumber: | 3524634507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME0085069 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME0085069 | 01 | FL | MEDICAL LICENSE | OTHER | 26550800 | 05 | FL | MEDICAID | 62987 | 01 | FL | BC | OTHER |