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Individual

BRUCE MALCOM LIDSTON

Active
Sole proprietor

Provider details

NPI number
Gender
Man
Credential
M.D.

Contact information

Practice address
1227 WARM SPRINGS AVE, J.C. BLAIR PHYSICIAN'S BUILDING #301, HUNTINGDON, PA 16652-2300
(814) 643-0531
(814) 643-6637
Mailing address
7297 LOVELAND DR, HUNTINGDON, PA 16652-4562
(814) 643-0766

Taxonomy

Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
MD016074E
PA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
000676816/0004
PA
Enumeration date
06/03/2006
Last updated
07/08/2007
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