1558366047 NPI number — DR. BRUCE J DREYFUSS M.D.

Table of content: DR. BRUCE J DREYFUSS M.D. (NPI 1558366047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558366047 NPI number — DR. BRUCE J DREYFUSS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREYFUSS
Provider First Name:
BRUCE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558366047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 N 14TH ST
Provider Second Line Business Mailing Address:
STE 890
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95112-6216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-288-6623
Provider Business Mailing Address Fax Number:
408-288-6698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 N 14TH ST
Provider Second Line Business Practice Location Address:
STE 890
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95112-6216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-288-6623
Provider Business Practice Location Address Fax Number:
408-288-6698
Provider Enumeration Date:
06/20/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  G64297 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2471B0102X , with the licence number: RHC142268 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X , with the licence number: FAC52131 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 660003967 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ54863Z . This is a "BLUE SHIELD #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 110048492 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 5148629 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".