Provider Demographics
NPI:1972901502
Name:DIETER BRUNO MD INC
Entity Type:Organization
Organization Name:DIETER BRUNO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-257-7257
Mailing Address - Street 1:2900 WHIPPLE AVE
Mailing Address - Street 2:SUITE 132
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2843
Mailing Address - Country:US
Mailing Address - Phone:650-257-7257
Mailing Address - Fax:
Practice Address - Street 1:1073 EDEN BOWER LN
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-1821
Practice Address - Country:US
Practice Address - Phone:650-257-7257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-13
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96007208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH38182Medicare UPIN
CA00A960070Medicare PIN