Provider Demographics
NPI:1245226232
Name:BRUCKNER, MARK NEIL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:NEIL
Last Name:BRUCKNER
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 1:2668 VIA ZURITA CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93012-9336
Mailing Address - Country:US
Mailing Address - Phone:805-491-2641
Mailing Address - Fax:
Practice Address - Street 1:2876 SYCAMORE DR
Practice Address - Street 2:SUITE 302
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1550
Practice Address - Country:US
Practice Address - Phone:805-522-4400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50614208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics