Provider Demographics
NPI:1124003975
Name:BRUECKNER, MARTINA (MD)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:BRUECKNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:BRUECKNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9805
Mailing Address - Street 2:300 GEORGE STREET 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:203-785-6610
Mailing Address - Fax:203-785-6414
Practice Address - Street 1:800 HOWARD AVENUE
Practice Address - Street 2:YALE PHYSICIANS BUILDING
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519
Practice Address - Country:US
Practice Address - Phone:203-785-2140
Practice Address - Fax:203-785-6414
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0290882080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001290882Medicaid
CT370000569Medicare PIN
CT001290882Medicaid