Provider Demographics
NPI:1871604611
Name:BRUNI, TIMOTHY G (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:BRUNI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:G
Other - Last Name:BRUNI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9454 THREE RIVERS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4294
Mailing Address - Country:US
Mailing Address - Phone:228-864-7747
Mailing Address - Fax:228-864-7415
Practice Address - Street 1:9454 THREE RIVERS RD
Practice Address - Street 2:SUITE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4294
Practice Address - Country:US
Practice Address - Phone:228-864-7747
Practice Address - Fax:228-864-7415
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15527208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015616Medicaid
MS00120712Medicaid
MS640935888OtherTAX IDENTIFICATION
MS$$$$$$$$$COtherBCBS
MS640935888OtherTAX IDENTIFICATION