Healthcare Provider Details

I. General information

NPI: 1932206851
Provider Name (Legal Business Name): BRUCE B CHISHOLM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39300 BOB HOPE DR BANNAN BLDG SUITE 1208
RANCHO MIRAGE CA
92270-3203
US

IV. Provider business mailing address

39300 BOB HOPE DR BANNAN BLDG SUITE 1208
RANCHO MIRAGE CA
92270-3203
US

V. Phone/Fax

Practice location:
  • Phone: 760-779-9559
  • Fax: 760-779-5077
Mailing address:
  • Phone: 760-779-9559
  • Fax: 760-779-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberG81937
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberG81937
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number10005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: