Healthcare Provider Details

I. General information

NPI: 1104882729
Provider Name (Legal Business Name): BRUCE M PRENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 CAMINO DEL RIO N # 120
SAN DIEGO CA
92108-1633
US

IV. Provider business mailing address

PO BOX 2305
SKYLAND NC
28776-2305
US

V. Phone/Fax

Practice location:
  • Phone: 619-286-6687
  • Fax: 619-286-6695
Mailing address:
  • Phone: 828-575-2644
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberG21931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: