Provider Demographics
NPI:1699785014
Name:REISMAN, BRUCE K (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:K
Last Name:REISMAN
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 1:3907 WARING RD STE 1A
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4454
Mailing Address - Country:US
Mailing Address - Phone:760-724-8749
Mailing Address - Fax:760-724-2604
Practice Address - Street 1:3907 WARING RD STE 1A
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4454
Practice Address - Country:US
Practice Address - Phone:760-724-8749
Practice Address - Fax:760-724-2604
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHLT4368207Y00000X
CAG59056207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G590560OtherBLUE SHIELD
CA00G590560Medicaid
CA00G590560OtherBLUE SHIELD
CAWG5905613Medicare ID - Type Unspecified