1184678765 NPI number — DR. ROBERT L BRUNK II DO

Table of content: DR. ROBERT L BRUNK II DO (NPI 1184678765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184678765 NPI number — DR. ROBERT L BRUNK II DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNK
Provider First Name:
ROBERT
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184678765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2264 U. S. HWY 30
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-477-5242
Provider Business Mailing Address Fax Number:
219-477-4859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 LAPORTE AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-5860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-477-5242
Provider Business Practice Location Address Fax Number:
219-477-4859
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  02001839A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02001839A . This is a "INDIANA LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 02001839B . This is a "CSR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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