Provider Demographics
NPI:1427693522
Name:BRELAND, BRUCE JEFFERSON
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:JEFFERSON
Last Name:BRELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:B.
Other - Middle Name:JEFFERSON
Other - Last Name:BRELAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4114 MARX AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5545
Mailing Address - Country:US
Mailing Address - Phone:410-336-5876
Mailing Address - Fax:
Practice Address - Street 1:1014 DULANEY VALLEY RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2702
Practice Address - Country:US
Practice Address - Phone:410-336-5876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001294171100000X
MDU02290171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist