Provider Demographics
NPI:1508831793
Name:BRUCK, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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 1:1229 MADISON ST
Mailing Address - Street 2:SUITE 1440
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3586
Mailing Address - Country:US
Mailing Address - Phone:206-625-0578
Mailing Address - Fax:206-625-9184
Practice Address - Street 1:1229 MADISON ST
Practice Address - Street 2:SUITE 1440
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3586
Practice Address - Country:US
Practice Address - Phone:206-625-0578
Practice Address - Fax:206-625-9184
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46946207L00000X
WAMD00048205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8482051Medicaid
MN923102100Medicaid
G8864991Medicare PIN
G000156100Medicare PIN
MN050001766Medicare ID - Type Unspecified
WA8482051Medicaid