Provider Demographics
NPI:1114160215
Name:BRUNSON, MICHAEL RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RYAN
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 PINION DRIVE, 10TH MEDICAL GROUP
Mailing Address - Street 2:
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2502
Mailing Address - Country:US
Mailing Address - Phone:719-333-3717
Mailing Address - Fax:
Practice Address - Street 1:35TH MDG
Practice Address - Street 2:UNIT 5024
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319
Practice Address - Country:US
Practice Address - Phone:315-226-6495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE26095208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics