Healthcare Provider Details

I. General information

NPI: 1487689121
Provider Name (Legal Business Name): BRUCE ALLEN FERRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1683 VENTURA BLVD
ENCINO CA
91436-1707
US

IV. Provider business mailing address

16830 VENTURA BLVD
ENCINO CA
91436-1707
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-0631
  • Fax: 310-794-2113
Mailing address:
  • Phone: 818-385-0273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberG60156
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberG60156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: