Provider Demographics
NPI:1063581833
Name:HAUPT, BRUCE FREDRIC (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:FREDRIC
Last Name:HAUPT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:610 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-766-7515
Practice Address - Fax:304-766-7566
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18234207X00000X
OH35-06-2182H207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0098202000Medicaid
OHP00665593OtherRR MEDICARE
OH2877347OtherOHIO MEDICAID - MOLINA
OH310917085194OtherOHIO MEDICAID - CARESOURCE
WVB441OtherGROUP MEDICARE
OH000000258093OtherOH MEDIICAID UNISON
OH2877347Medicaid
WV3810024049OtherGROUP MEDICAID
OHHA0786335Medicare PIN
OH2877347OtherOHIO MEDICAID - MOLINA
OH2877347Medicaid