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General NPI Number Information
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NPI Number | 1932206851
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Entity Type | Individual
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Provider Name | BRUCE B CHISHOLM M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 10/06/2011
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Provider Practice Location Address
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Address Line | 39300 BOB HOPE DR BANNAN BLDG SUITE 1208
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-3203
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Country | US
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Telephone | 760-779-9559
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Fax | 760-779-5077
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Provider Business Mailing Address
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Address Line | 39300 BOB HOPE DR BANNAN BLDG SUITE 1208
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-3203
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Country | US
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Telephone | 760-779-9559
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Fax | 760-779-5077
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | G81937
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | G81937
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 10005
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License Number State | CA
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