Basic Information
Provider Information | |||||||||
NPI: | 1124003975 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRUECKNER | ||||||||
FirstName: | MARTINA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRUECKNER | ||||||||
OtherFirstName: | TINA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9805 | ||||||||
Address2: | 300 GEORGE STREET 6TH FLOOR | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065360805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037856610 | ||||||||
FaxNumber: | 2037856414 | ||||||||
Practice Location | |||||||||
Address1: | 800 HOWARD AVENUE | ||||||||
Address2: | YALE PHYSICIANS BUILDING | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 06519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037852140 | ||||||||
FaxNumber: | 2037856414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2005 | ||||||||
LastUpdateDate: | 07/21/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 029088 | CT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
ID | Type | State | Issuer | Description | 001290882 | 05 | CT |   | MEDICAID |