Provider Demographics
NPI:1548281496
Name:POTENZA, BRUCE MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MICHAEL
Last Name:POTENZA
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:800-926-8273
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:619-543-7200
Practice Address - Fax:619-543-7202
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77333207RC0200X, 2086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G773330Medicaid
CAWG77333BMedicare ID - Type Unspecified
CA00G773330Medicaid