Provider Demographics
NPI:1376500835
Name:BRUKER, CHARLES TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TODD
Last Name:BRUKER
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:PO BOX 741087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1087
Mailing Address - Country:US
Mailing Address - Phone:912-350-8013
Mailing Address - Fax:912-350-8437
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-8013
Practice Address - Fax:912-350-8437
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL32816207ZH0000X, 207ZP0102X
GA074012207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL153282Medicaid
AL153282Medicaid
AL1376500835Medicare UPIN