Provider Demographics
NPI:1568787141
Name:BUNN, BRYAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
Last Name:BUNN
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 1:113 VIRGINIA RD
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1446
Mailing Address - Country:US
Mailing Address - Phone:252-482-3047
Mailing Address - Fax:252-482-5061
Practice Address - Street 1:113 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1446
Practice Address - Country:US
Practice Address - Phone:252-482-3047
Practice Address - Fax:252-482-5061
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2013-01771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1568787141Medicaid
NC1568787141Medicaid