Basic Information
| Provider Information | |||||||||
| NPI: | 1932175106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7287 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977087287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476263 | ||||||||
| FaxNumber: | 5414474698 | ||||||||
| Practice Location | |||||||||
| Address1: | 384 SE COMBS FLAT RD | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977542562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476263 | ||||||||
| FaxNumber: | 5414478724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD14210 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 269803 | 05 | OR | MEDICAID |