Provider Demographics
NPI:1316048382
Name:BRUCE-LYLE, LESLIE ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ALEXANDER
Last Name:BRUCE-LYLE
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 1:11306 MOUNTAIN VIEW AVE STE E
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3832
Mailing Address - Country:US
Mailing Address - Phone:909-799-1992
Mailing Address - Fax:909-799-1499
Practice Address - Street 1:11306 MOUNTAIN VIEW AVE STE E
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3832
Practice Address - Country:US
Practice Address - Phone:909-799-1992
Practice Address - Fax:909-799-1499
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51441207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH489YMedicare PIN
CABH489ZMedicare PIN
CAF49423Medicare UPIN