Provider Demographics
NPI:1497745202
Name:BUNTIC, RUDOLF FABIAN (MD)
Entity Type:Individual
Prefix:
First Name:RUDOLF
Middle Name:FABIAN
Last Name:BUNTIC
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 1:45 CASTRO ST
Mailing Address - Street 2:SUITE 121
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-1010
Mailing Address - Country:US
Mailing Address - Phone:415-565-6136
Mailing Address - Fax:415-864-1654
Practice Address - Street 1:45 CASTRO ST
Practice Address - Street 2:STE 121
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1010
Practice Address - Country:US
Practice Address - Phone:415-565-6136
Practice Address - Fax:415-864-1654
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG742502086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G742500Medicaid
CA00G742500OtherBLUE SHIELD
F97708Medicare UPIN