Provider Demographics
NPI:1356450449
Name:BRUNT, ROGER S (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:S
Last Name:BRUNT
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 1:2340 VIRLOW ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3323
Mailing Address - Country:US
Mailing Address - Phone:208-523-2340
Mailing Address - Fax:
Practice Address - Street 1:2340 VIRLOW ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3323
Practice Address - Country:US
Practice Address - Phone:208-523-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1110037Medicare ID - Type Unspecified
IDC36829Medicare UPIN