1558192575 NPI number — MR. NATHANAEL OWEN BUNGARD DPT

Table of content: MR. NATHANAEL OWEN BUNGARD DPT (NPI 1558192575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558192575 NPI number — MR. NATHANAEL OWEN BUNGARD DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUNGARD
Provider First Name:
NATHANAEL
Provider Middle Name:
OWEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1558192575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
638 ROSTRAVER RD
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
BELLE VERNON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-243-3728
Provider Business Mailing Address Fax Number:
724-320-2254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
638 ROSTRAVER RD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
BELLE VERNON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-243-3728
Provider Business Practice Location Address Fax Number:
724-320-2254
Provider Enumeration Date:
08/12/2024

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: 225100000X , with the licence number:  PT032461 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com