Healthcare Provider Details

I. General information

NPI: 1164630026
Provider Name (Legal Business Name): DANIEL LEE BRUCH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-7320
  • Fax:
Mailing address:
  • Phone: 909-376-4438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A9501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: