Provider Demographics
NPI:1982102539
Name:TEDLA, BRUKE
Entity type:Individual
Prefix:
First Name:BRUKE
Middle Name:
Last Name:TEDLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2068 ORANGE TREE LN STE 215
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11324 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1728
Practice Address - Country:US
Practice Address - Phone:909-558-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2025-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160609207RA0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease