Provider Demographics
NPI:1487692117
Name:BRUICE, KENTON T (MD)
Entity type:Individual
Prefix:DR
First Name:KENTON
Middle Name:T
Last Name:BRUICE
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 1:100 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1780
Mailing Address - Country:US
Mailing Address - Phone:970-925-6655
Mailing Address - Fax:970-920-6738
Practice Address - Street 1:100 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-1780
Practice Address - Country:US
Practice Address - Phone:970-925-6655
Practice Address - Fax:970-920-6738
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37319174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01373190Medicaid
CO01373190Medicaid
COC37319Medicare PIN