Healthcare Provider Details

I. General information

NPI: 1033189055
Provider Name (Legal Business Name): MICHAEL L. BRUCK M.D., F.A.A.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10115 W FOREST HILL BLVD. SUITE 402
WELLINGTON FL
33414
US

IV. Provider business mailing address

10115 W FOREST HILL BLVD. SUITE 402
WELLINGTON FL
33414
US

V. Phone/Fax

Practice location:
  • Phone: 561-791-1935
  • Fax: 561-791-0115
Mailing address:
  • Phone: 561-791-1935
  • Fax: 561-791-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME-0069990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: