Provider Demographics
NPI:1366448854
Name:BRUCK, RICHARD L (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
Last Name:BRUCK
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 1:591 N 13TH AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4968
Mailing Address - Country:US
Mailing Address - Phone:909-985-5885
Mailing Address - Fax:909-920-3379
Practice Address - Street 1:591 N 13TH AVE
Practice Address - Street 2:STE 3
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4968
Practice Address - Country:US
Practice Address - Phone:909-985-5885
Practice Address - Fax:909-920-3379
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30560207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G305600Medicare ID - Type Unspecified
A44468Medicare UPIN