Provider Demographics
NPI:1710034467
Name:BRUCKER, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BRUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9850 GENESEE AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1213
Mailing Address - Country:US
Mailing Address - Phone:858-450-1776
Mailing Address - Fax:858-450-9446
Practice Address - Street 1:9850 GENESEE AVE STE 500
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1213
Practice Address - Country:US
Practice Address - Phone:858-450-1776
Practice Address - Fax:858-450-9446
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA79133208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH68874Medicare UPIN