Healthcare Provider Details

I. General information

NPI: 1508292996
Provider Name (Legal Business Name): EMILY BRUCKNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 WILSHIRE BLVD STE 120
LOS ANGELES CA
90025-1099
US

IV. Provider business mailing address

12301 WILSHIRE BLVD STE 120
LOS ANGELES CA
90025-1099
US

V. Phone/Fax

Practice location:
  • Phone: 310-979-7337
  • Fax: 310-979-7338
Mailing address:
  • Phone: 310-979-7337
  • Fax: 310-979-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA124722
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: