Provider Demographics
NPI:1053640763
Name:BRUNSON, MATT E (MD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:E
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ELDRED
Other - Middle Name:MATTATHA
Other - Last Name:BRUNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2411 ROYAL LN
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-2622
Mailing Address - Country:US
Mailing Address - Phone:205-908-8770
Mailing Address - Fax:205-733-9269
Practice Address - Street 1:2411 ROYAL LN
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-2622
Practice Address - Country:US
Practice Address - Phone:205-908-8770
Practice Address - Fax:205-733-9269
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11237208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC69983Medicare UPIN