Provider Demographics
NPI:1629104617
Name:WERMUTH, BRUCE MELVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MELVIN
Last Name:WERMUTH
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 1:2190 COWPER STREET
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301
Mailing Address - Country:US
Mailing Address - Phone:650-327-5153
Mailing Address - Fax:
Practice Address - Street 1:2542 S BASCOM AVE
Practice Address - Street 2:STE 110
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-5526
Practice Address - Country:US
Practice Address - Phone:408-559-3403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG255812084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G255810Medicare PIN