Healthcare Provider Details

I. General information

NPI: 1710034467
Provider Name (Legal Business Name): MICHAEL J BRUCKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 500
LA JOLLA CA
92037-1213
US

IV. Provider business mailing address

9850 GENESEE AVE STE 500
LA JOLLA CA
92037-1213
US

V. Phone/Fax

Practice location:
  • Phone: 858-450-1776
  • Fax: 858-450-9446
Mailing address:
  • Phone: 858-450-1776
  • Fax: 858-450-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA79133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: