Provider Demographics
NPI:1093758310
Name:BRUZA, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:BRUZA
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 1:3615 CHESTNUT STREET
Mailing Address - Street 2:RALSTON - PENN CENTER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2612
Mailing Address - Country:US
Mailing Address - Phone:215-662-2746
Mailing Address - Fax:215-349-5648
Practice Address - Street 1:3615 CHESTNUT STREET
Practice Address - Street 2:RALSTON - PENN CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2612
Practice Address - Country:US
Practice Address - Phone:215-662-2746
Practice Address - Fax:215-349-5648
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064174L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016745200001Medicaid
PA529601Medicare PIN
F95509Medicare UPIN