Healthcare Provider Details

I. General information

NPI: 1821304882
Provider Name (Legal Business Name): TAYLOR J BRUESEKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

200 S MANCHESTER AVE # 310
ORANGE CA
92868-3217
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-2911
  • Fax: 855-209-8413
Mailing address:
  • Phone: 714-456-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA121053
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberA121053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: