Provider Demographics
NPI:1679544225
Name:HIGGINBOTHAM, BRUCE WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:WAYNE
Last Name:HIGGINBOTHAM
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 1:101 E 26TH STREET
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98421
Mailing Address - Country:US
Mailing Address - Phone:253-722-1837
Mailing Address - Fax:253-722-1851
Practice Address - Street 1:10510 GRAVELLY LAKE DR SW
Practice Address - Street 2:COMMUNITY HEALTH CARE
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-5036
Practice Address - Country:US
Practice Address - Phone:253-722-1837
Practice Address - Fax:253-722-1851
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043885207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00385219OtherRAILROAD MEDICARE
AR164111001Medicaid
AR5N787Medicare PIN