Provider Demographics
NPI:1295868024
Name:SANDRA D.M. BRUNO, M.D., LLC
Entity Type:Organization
Organization Name:SANDRA D.M. BRUNO, M.D., LLC
Other - Org Name:MOSS BLUFF MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-217-1000
Mailing Address - Street 1:217 SAM HOUSTON JONES PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-5603
Mailing Address - Country:US
Mailing Address - Phone:337-217-1000
Mailing Address - Fax:
Practice Address - Street 1:217 SAM HOUSTON JONES PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5603
Practice Address - Country:US
Practice Address - Phone:337-217-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020956207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1677027Medicaid
F80249Medicare UPIN
LA1677027Medicaid