Provider Demographics
NPI:1639257546
Name:BRUNST, ROBERT FRITS (MD PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:FRITS
Last Name:BRUNST
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 N EL CAMINO REAL
Mailing Address - Street 2:STE A200
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:760-942-1242
Mailing Address - Fax:760-942-7840
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:STE A200
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024
Practice Address - Country:US
Practice Address - Phone:760-942-1242
Practice Address - Fax:760-942-7840
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36956207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG369560Medicaid
5127318OtherMCAC PIN
CAG369560Medicaid
A46882Medicare UPIN
G36956Medicare ID - Type UnspecifiedLIC #