Provider Demographics
NPI:1073562203
Name:BRUKSCH, LAWRENCE MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:MICHAEL
Last Name:BRUKSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 SANTA MONICA BLVD.
Mailing Address - Street 2:SUITE 468W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-255-0990
Mailing Address - Fax:310-255-0996
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 468W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2180
Practice Address - Country:US
Practice Address - Phone:310-255-0990
Practice Address - Fax:310-255-0996
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31595174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14051Medicare ID - Type UnspecifiedPROVIDER NUMBER
CAA91349Medicare UPIN