Provider Demographics
NPI:1891779534
Name:BRUNVAND, MARK WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILSON
Last Name:BRUNVAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:720-754-4800
Mailing Address - Fax:720-754-4801
Practice Address - Street 1:1721 E 19TH AVE
Practice Address - Street 2:STE 300
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1251
Practice Address - Country:US
Practice Address - Phone:720-754-4800
Practice Address - Fax:720-754-4801
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2014-02-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO26243207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117831800Medicaid
WY1891779534Medicaid
KS200604790BMedicaid
KS200604791BMedicaid
NM37709003Medicaid
CO01026244Medicaid
NE10025893500Medicaid
WY117831800Medicaid
COCOA103222Medicare PIN
COP00937758Medicare PIN
KS200604790BMedicaid