Provider Demographics
NPI:1104882729
Name:PRENNER, BRUCE M (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:PRENNER
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:PO BOX 2305
Mailing Address - Street 2:
Mailing Address - City:SKYLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28776-2305
Mailing Address - Country:US
Mailing Address - Phone:828-575-2644
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:2655 CAMINO DEL RIO N
Practice Address - Street 2:# 120
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1633
Practice Address - Country:US
Practice Address - Phone:619-286-6687
Practice Address - Fax:619-286-6695
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21931207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G219310Medicaid
CAGW214ZOtherMEDICARE PTAN