Provider Demographics
NPI:1285619221
Name:OUELLETTE, BRUCE V (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:V
Last Name:OUELLETTE
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 1:383 SE MULBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-2310
Mailing Address - Country:US
Mailing Address - Phone:850-865-2644
Mailing Address - Fax:
Practice Address - Street 1:10000 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2111
Practice Address - Country:US
Practice Address - Phone:954-345-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME849322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265032100Medicaid
H76212Medicare UPIN