Provider Demographics
NPI:1659768588
Name:BRUNNER, BRENDEN (MD)
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:
Last Name:BRUNNER
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:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08754-1120
Mailing Address - Country:US
Mailing Address - Phone:503-789-2990
Mailing Address - Fax:
Practice Address - Street 1:14 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6402
Practice Address - Country:US
Practice Address - Phone:503-789-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11373100207R00000X
LAMD.309290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2387952Medicaid