Provider Demographics
NPI:1770646721
Name:BRUNZLICK, LARRY R (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:BRUNZLICK
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 1:135 SOUTH GIBSON STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451
Mailing Address - Country:US
Mailing Address - Phone:715-748-8100
Mailing Address - Fax:
Practice Address - Street 1:135 SOUTH GIBSON STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451
Practice Address - Country:US
Practice Address - Phone:715-748-8100
Practice Address - Fax:715-748-7590
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24477207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30461100Medicaid
WIB51805Medicare UPIN
WI0005Medicare ID - Type Unspecified