Provider Demographics
NPI:1700844164
Name:LANDRES, BRUCE C (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:LANDRES
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 1:11645 WILSHIRE BLVD
Mailing Address - Street 2:STE 901
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6810
Mailing Address - Country:US
Mailing Address - Phone:310-481-0481
Mailing Address - Fax:310-481-0482
Practice Address - Street 1:11645 WILSHIRE BLVD
Practice Address - Street 2:STE 901
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6810
Practice Address - Country:US
Practice Address - Phone:310-481-0481
Practice Address - Fax:310-481-0482
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25226207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A42578Medicare UPIN
W17916Medicare ID - Type Unspecified