Healthcare Provider Details

I. General information

NPI: 1366448854
Provider Name (Legal Business Name): RICHARD L BRUCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 N 13TH AVE STE 3
UPLAND CA
91786-4968
US

IV. Provider business mailing address

591 N 13TH AVE STE 3
UPLAND CA
91786-4968
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-5885
  • Fax: 909-920-3379
Mailing address:
  • Phone: 909-985-5885
  • Fax: 909-920-3379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG30560
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG30560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: