Provider Demographics
NPI:1558360909
Name:BUNDY, SCOTT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:BUNDY
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0387
Mailing Address - Fax:
Practice Address - Street 1:815 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2224
Practice Address - Country:US
Practice Address - Phone:817-321-0387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK26562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125329605Medicaid
TN125329608Medicaid
TX1253296-10Medicaid
TX89374RMedicare ID - Type Unspecified'OTHER' COUNTIES
TX1253296-10Medicaid
TN125329608Medicaid
TXTXB120626Medicare PIN