Provider Demographics
NPI:1760462824
Name:EISENDORF, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:EISENDORF
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 1:2025 SOQUEL AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1323
Mailing Address - Country:US
Mailing Address - Phone:831-458-5524
Mailing Address - Fax:
Practice Address - Street 1:2025 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1323
Practice Address - Country:US
Practice Address - Phone:831-458-5524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F37476Medicare UPIN