Provider Demographics
NPI:1689784860
Name:BRUNZIE, MARY (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BRUNZIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S SEMINOLE AVE
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4735
Mailing Address - Country:US
Mailing Address - Phone:352-344-6481
Mailing Address - Fax:352-344-3920
Practice Address - Street 1:7945 S SUNCOAST BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5005
Practice Address - Country:US
Practice Address - Phone:352-382-6111
Practice Address - Fax:352-382-6112
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS007346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251202500Medicaid
FL251202500Medicaid
FL251202500Medicaid