Provider Demographics
NPI:1912031907
Name:CUNNINGHAM, BRUCE D (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 E CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-8400
Mailing Address - Country:US
Mailing Address - Phone:856-691-1053
Mailing Address - Fax:856-691-9561
Practice Address - Street 1:2630 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361-8400
Practice Address - Country:US
Practice Address - Phone:856-691-1053
Practice Address - Fax:856-691-9561
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02500000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1994301Medicaid
NJCU455699Medicare ID - Type UnspecifiedMEDICARE NUMBER
NJ1994301Medicaid