Provider Demographics
NPI:1790316206
Name:BUNN, ANTJUAN MANDWELL
Entity Type:Individual
Prefix:
First Name:ANTJUAN
Middle Name:MANDWELL
Last Name:BUNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-2123
Mailing Address - Country:US
Mailing Address - Phone:240-398-1909
Mailing Address - Fax:
Practice Address - Street 1:8147 BALTIMORE AVE STE C
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2492
Practice Address - Country:US
Practice Address - Phone:240-398-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2218861744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management