Provider Demographics
NPI:1114102134
Name:BRUNTEL, MATTHEW HERBERT (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HERBERT
Last Name:BRUNTEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 POWDER HORN DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2539
Mailing Address - Country:US
Mailing Address - Phone:202-604-1405
Mailing Address - Fax:
Practice Address - Street 1:15245 SHADY GROVE RD STE 130
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-527-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD020449800Medicaid
MD137397Medicare PIN