Provider Demographics
NPI:1447330626
Name:BRUCKNER, IRWIN BARRY (MD)
Entity type:Individual
Prefix:
First Name:IRWIN
Middle Name:BARRY
Last Name:BRUCKNER
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 1:5400 BALBOA BLVD STE 326
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5214
Mailing Address - Country:US
Mailing Address - Phone:818-789-0492
Mailing Address - Fax:818-789-6726
Practice Address - Street 1:5400 BALBOA BLVD STE 326
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5214
Practice Address - Country:US
Practice Address - Phone:818-789-0492
Practice Address - Fax:818-789-6726
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42765208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics