Provider Demographics
NPI:1871573097
Name:BRUCKNER, BRIAN ALLEN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALLEN
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 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:1150 N 35TH AVE STE 440
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5430
Practice Address - Country:US
Practice Address - Phone:954-265-6356
Practice Address - Fax:954-985-5154
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS30631204F00000X, 208G00000X
TN66242204F00000X, 208G00000X
TXK7670208G00000X
FLME141685208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107116700Medicaid
TX137417516Medicaid
TX137417517Medicaid
TX137417518Medicaid
TX8W1059OtherBCBS
TX8W1059OtherBLUE CROSS BLUE SHIELD
TX137417518Medicaid
TXH05467Medicare UPIN
TX137417517Medicaid
TX536370ZSWDMedicare PIN
TX137417518Medicaid
TXTXB145136Medicare PIN