Basic Information
Provider Information | |||||||||
NPI: | 1194913624 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RICHARD L BRUCK M D A PROFESSIONAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 591 N 13TH AVE | ||||||||
Address2: | STE.3 | ||||||||
City: | UPLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 917864967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099855885 | ||||||||
FaxNumber: | 9099203379 | ||||||||
Practice Location | |||||||||
Address1: | 591 N 13TH AVE | ||||||||
Address2: | STE.3 | ||||||||
City: | UPLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 917864967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512178640 | ||||||||
FaxNumber: | 9099203379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2007 | ||||||||
LastUpdateDate: | 10/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUCK | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | LAWRENCE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9512178640 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | I | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G30560 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.