Provider Demographics
NPI:1275647356
Name:CULBERTSON, BRUCE A (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:CULBERTSON
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 1:1661 E CAMELBACK RD STE 205
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3913
Mailing Address - Country:US
Mailing Address - Phone:602-422-9000
Mailing Address - Fax:602-556-5951
Practice Address - Street 1:530 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3204
Practice Address - Country:US
Practice Address - Phone:602-351-2229
Practice Address - Fax:602-351-1500
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24097207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF79585Medicare UPIN
AZMD20705Medicare ID - Type Unspecified