Provider Demographics
NPI:1114920535
Name:BRUCE, HENRY E (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:E
Last Name:BRUCE
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 1:24411 HEALTH CENTER DR
Mailing Address - Street 2:STE 320
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3633
Mailing Address - Country:US
Mailing Address - Phone:949-770-6077
Mailing Address - Fax:949-770-0869
Practice Address - Street 1:24411 HEALTH CENTER DR
Practice Address - Street 2:STE 320
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3633
Practice Address - Country:US
Practice Address - Phone:949-770-6077
Practice Address - Fax:949-770-0869
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2007-12-21
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
CAG17513174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40103Medicare UPIN
CAG17513Medicare PIN
CA0787000001Medicare NSC