Provider Demographics
NPI:1134702699
Name:BRUNSON, MAKAYLA R (MD)
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:R
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAKAYLA
Other - Middle Name:R
Other - Last Name:RILES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1900 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-6948
Mailing Address - Country:US
Mailing Address - Phone:706-571-1430
Mailing Address - Fax:
Practice Address - Street 1:1900 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:229-591-6597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program