Healthcare Provider Details

I. General information

NPI: 1114104981
Provider Name (Legal Business Name): CHARLES EUGENE BRUSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 SILVER CREEK RD SUITE 115
BULLHEAD CITY AZ
86442-7904
US

IV. Provider business mailing address

2755 SILVER CREEK RD SUITE 115
BULLHEAD CITY AZ
86442-7904
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-3600
  • Fax: 928-763-5700
Mailing address:
  • Phone: 928-763-3600
  • Fax: 928-763-5700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number23430
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: