Provider Demographics
NPI:1700416807
Name:BRUDER, JACQUELINE K (PMD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:K
Last Name:BRUDER
Suffix:
Gender:F
Credentials:PMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 SW 137TH TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-1132
Mailing Address - Country:US
Mailing Address - Phone:954-214-4426
Mailing Address - Fax:
Practice Address - Street 1:1625 N COMMERCE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3206
Practice Address - Country:US
Practice Address - Phone:954-765-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJA7201247200000X, 146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other