MEDICARE: DR. BRUCE MICHAEL POTENZA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	G77333	CA
2	2086S0127X	Trauma Surgery Physician	G77333	CA
3	2086S0102X	Surgical Critical Care Physician	G77333	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548281496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE MICHAEL POTENZA MD

Provider Business Mailing Address
First Line	:	PO BOX 232410
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92193-2410
Country	:	US
Telephone Number	:	800-926-8273
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 W ARBOR DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-9001
Country	:	US
Telephone Number	:	619-543-7200
Fax Number	:	619-543-7202

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	02/23/2021

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