Provider Demographics
NPI:1033259387
Name:BRUNER, GARY WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
Last Name:BRUNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 PINNACLES ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-6658
Mailing Address - Country:US
Mailing Address - Phone:530-759-1266
Mailing Address - Fax:
Practice Address - Street 1:6100 SUNRISE MALL
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-6906
Practice Address - Country:US
Practice Address - Phone:916-721-1466
Practice Address - Fax:916-726-0658
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8066T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0080660Medicaid
SD0080660Medicare ID - Type Unspecified
CASD0080660Medicaid