Healthcare Provider Details

I. General information

NPI: 1871694315
Provider Name (Legal Business Name): BRUCE L MALTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 BALDWIN AVE
SAN MATEO CA
94401-3915
US

IV. Provider business mailing address

280 BALDWIN AVE
SAN MATEO CA
94401-3915
US

V. Phone/Fax

Practice location:
  • Phone: 650-344-1121
  • Fax: 650-344-1069
Mailing address:
  • Phone: 650-344-1121
  • Fax: 650-344-1069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG40607
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG40607
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG40607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: