Provider Demographics
NPI:1194799692
Name:NELSON, BRUCE A (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2925 SYCAMORE DR
Mailing Address - Street 2:SUITE 204/205
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1207
Mailing Address - Country:US
Mailing Address - Phone:805-578-9620
Mailing Address - Fax:805-583-0414
Practice Address - Street 1:2925 SYCAMORE DR
Practice Address - Street 2:SUITE 204/205
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1207
Practice Address - Country:US
Practice Address - Phone:805-578-9620
Practice Address - Fax:805-955-0498
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2020-03-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG36931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G369310Medicaid
CAA46870Medicare UPIN