Provider Demographics
NPI:1417949876
Name:BUNNELL, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BUNNELL
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-572-3366
Mailing Address - Fax:859-572-3568
Practice Address - Street 1:85 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1793
Practice Address - Country:US
Practice Address - Phone:859-572-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64159809Medicaid
C72701Medicare UPIN
KY64159809Medicaid