Provider Demographics
NPI:1497076376
Name:BRUCKER, KRISTA M (MD)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:BRUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 W GREEN MEADOWS DR STE 2
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-4000
Practice Address - Country:US
Practice Address - Phone:317-318-0367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071924A207P00000X, 2084A0401X, 2083A0300X
IAMD-496012083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201212140Medicaid
IN200640015Medicare PIN
IN201212140Medicaid