Healthcare Provider Details

I. General information

NPI: 1245226232
Provider Name (Legal Business Name): MARK NEIL BRUCKNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2876 SYCAMORE DR SUITE 302
SIMI VALLEY CA
93065-1550
US

IV. Provider business mailing address

2668 VIA ZURITA CT
SANTA ROSA VALLEY CA
93012-9336
US

V. Phone/Fax

Practice location:
  • Phone: 805-522-4400
  • Fax:
Mailing address:
  • Phone: 805-491-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG50614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: