Provider Demographics
NPI: | 1821062670 |
---|---|
Name: | BRUNET, MICHAEL ELDEN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | ELDEN |
Last Name: | BRUNET |
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: | 3444 MASONIC DR |
Mailing Address - Street 2: | |
Mailing Address - City: | ALEXANDRIA |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 71301-3615 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 318-473-9556 |
Mailing Address - Fax: | 318-441-8339 |
Practice Address - Street 1: | 3351 MASONIC DR |
Practice Address - Street 2: | |
Practice Address - City: | ALEXANDRIA |
Practice Address - State: | LA |
Practice Address - Zip Code: | 71301-3842 |
Practice Address - Country: | US |
Practice Address - Phone: | 318-473-9556 |
Practice Address - Fax: | 318-441-8339 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-02-16 |
Last Update Date: | 2021-04-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | MD012256 | 207XX0005X, 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
LA | 1189081 | Medicaid | |
LA | 1189081 | Medicaid | |
LA | 5J019F735 | Medicare ID - Type Unspecified |