Basic Information
| Provider Information | |||||||||
| NPI: | 1255422192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013758858 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 5957 FASHION POINT DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844035180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755683 | ||||||||
| FaxNumber: | 8014759499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 5181983-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200302299 | 01 | UT | TAX ID | OTHER |