Provider Demographics
NPI:1215011580
Name:BRUCE P. DECARLO, MD, INC.
Entity Type:Organization
Organization Name:BRUCE P. DECARLO, MD, INC.
Other - Org Name:THOMAS J. PURTZER, MD, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-441-1242
Mailing Address - Street 1:373 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1040
Mailing Address - Country:US
Mailing Address - Phone:714-441-1242
Mailing Address - Fax:714-441-2449
Practice Address - Street 1:7407 N CEDAR AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3839
Practice Address - Country:US
Practice Address - Phone:559-440-9904
Practice Address - Fax:559-440-9420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA034681208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27552Medicare UPIN
CAS29360Medicare UPIN
CAZZZ32119ZMedicare ID - Type Unspecified