Provider Demographics
NPI:1487689121
Name:FERRELL, BRUCE ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:FERRELL
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 1:16830 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1707
Mailing Address - Country:US
Mailing Address - Phone:818-385-0273
Mailing Address - Fax:
Practice Address - Street 1:1683 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1707
Practice Address - Country:US
Practice Address - Phone:310-825-0631
Practice Address - Fax:310-794-2113
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60156207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G601560Medicaid
CAD38780Medicare UPIN
CAWG60156AMedicare PIN