Provider Demographics
NPI:1780608794
Name:BRUCKER-BUSSO, ANNE W (MD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:W
Last Name:BRUCKER-BUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-1981
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1425 MALABAR RD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2506
Practice Address - Country:US
Practice Address - Phone:321-434-8078
Practice Address - Fax:321-434-8075
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10155207R00000X
FLME124930207R00000X, 208M00000X
WI43191207R00000X
WA60074658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIL931ZOtherMEDICARE
FL016887700Medicaid