Provider Demographics
NPI:1578619797
Name:BRUNETTI, JAMES A (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:BRUNETTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 LAKE AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4519
Mailing Address - Country:US
Mailing Address - Phone:203-900-1090
Mailing Address - Fax:203-900-1092
Practice Address - Street 1:49 LAKE AVE STE 206
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:203-900-1090
Practice Address - Fax:203-900-1092
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02075703Medicaid
CT001004655Medicaid
CT040000465CT02OtherANTHEM BLUE CROSS
CT001004655Medicaid
P00055617Medicare ID - Type UnspecifiedRAILROAD MEDICARE
G51804Medicare UPIN