Provider Demographics
NPI:1902396898
Name:BUNDY, JACOB JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JOSEPH
Last Name:BUNDY
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:WAKE FOREST BAPTIST HEALTH MEDICAL CENTER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1088
Mailing Address - Country:US
Mailing Address - Phone:336-716-3560
Mailing Address - Fax:
Practice Address - Street 1:WAKE FOREST BAPTIST HEALTH MEDICAL CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-5331
Practice Address - Country:US
Practice Address - Phone:336-716-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2485132085B0100X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging