Healthcare Provider Details

I. General information

NPI: 1649354150
Provider Name (Legal Business Name): ANNA L BRUCKNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13123 E 16TH AVE CHILDREN'S HOSPITAL COLORADO
AURORA CO
80045-7106
US

IV. Provider business mailing address

PO BOX 110429 UNIVERSITY PHYSICIANS, INC.
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-1234
  • Fax:
Mailing address:
  • Phone: 303-493-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number37780
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number37780
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: