Provider Demographics
NPI:1164690111
Name:BRUCKERHOFF, DENISE KAY (DO)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:KAY
Last Name:BRUCKERHOFF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:DENISE
Other - Middle Name:KAY
Other - Last Name:NUSSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 MATLOCK RD BLDG 6
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4391
Mailing Address - Country:US
Mailing Address - Phone:817-755-1005
Mailing Address - Fax:817-755-8499
Practice Address - Street 1:1900 MATLOCK RD BLDG 6
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4391
Practice Address - Country:US
Practice Address - Phone:817-755-1005
Practice Address - Fax:817-755-8499
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203462103Medicaid
TX203462101Medicaid
TX203462102Medicaid
TX203462104Medicaid
TX538516YL7AMedicare PIN
TX203462104Medicaid
8L14836Medicare PIN
TX538516YL7BMedicare PIN