Basic Information
| Provider Information | |||||||||
| NPI: | 1629187448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUHN | ||||||||
| FirstName: | FREDERIC | ||||||||
| MiddleName: | WALTER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 765 CALLE LOS OLIVOS | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926732717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597602202 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4460 E HUNTINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937022962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594594300 | ||||||||
| FaxNumber: | 5594594569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 12/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G43549 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CA | MEDICAID |