Provider Demographics
NPI:1932206851
Name:CHISHOLM, BRUCE B (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:B
Last Name:CHISHOLM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:39300 BOB HOPE DR
Mailing Address - Street 2:BANNAN BLDG SUITE 1208
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3203
Mailing Address - Country:US
Mailing Address - Phone:760-779-9559
Mailing Address - Fax:760-779-5077
Practice Address - Street 1:39300 BOB HOPE DR
Practice Address - Street 2:BANNAN BLDG SUITE 1208
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3203
Practice Address - Country:US
Practice Address - Phone:760-779-9559
Practice Address - Fax:760-779-5077
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG81937204E00000X, 2086S0122X
CA10005261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G819370Medicare ID - Type Unspecified
CAG22112Medicare UPIN