Provider Demographics
NPI:1417934662
Name:BUNTING-BLAKE, GERALD FRANK (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:FRANK
Last Name:BUNTING-BLAKE
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 1:2125 E GOLF AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4031
Mailing Address - Country:US
Mailing Address - Phone:480-201-0781
Mailing Address - Fax:
Practice Address - Street 1:5380 E KACHINA ST
Practice Address - Street 2:
Practice Address - City:DAVIS MONTHAN A F B
Practice Address - State:AZ
Practice Address - Zip Code:85707-4923
Practice Address - Country:US
Practice Address - Phone:520-228-4926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31378207Q00000X, 2084P0800X
NE13051207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine