Provider Demographics
NPI:1598795494
Name:WEBBER, BRUCE LEONARD (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:LEONARD
Last Name:WEBBER
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 1:6046 KNIGHT ARNOLD ROAD EXT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-3347
Mailing Address - Country:US
Mailing Address - Phone:901-542-6801
Mailing Address - Fax:901-542-6871
Practice Address - Street 1:6046 KNIGHT ARNOLD ROAD EXT
Practice Address - Street 2:SUITE 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3347
Practice Address - Country:US
Practice Address - Phone:901-542-6801
Practice Address - Fax:901-542-6871
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000012393207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000000005210Medicaid
TN3025108OtherBLUE CROSS BLUE SHIELD
TN3025108Medicaid
TN3041868Medicaid
AR96813OtherBLUE CROSS
AR96813OtherBLUE CROSS
TN3041865Medicare ID - Type Unspecified
TN3041868Medicaid