Provider Demographics
NPI:1942528369
Name:DANIEL M BRUDNAK MD FAAFP PA
Entity Type:Organization
Organization Name:DANIEL M BRUDNAK MD FAAFP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRUDNAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-734-4254
Mailing Address - Street 1:P O BOX 417
Mailing Address - Street 2:
Mailing Address - City:GORMAN
Mailing Address - State:TX
Mailing Address - Zip Code:76454
Mailing Address - Country:US
Mailing Address - Phone:254-734-4254
Mailing Address - Fax:254-734-4355
Practice Address - Street 1:115 S KENT ST
Practice Address - Street 2:
Practice Address - City:GORMAN
Practice Address - State:TX
Practice Address - Zip Code:76454-3060
Practice Address - Country:US
Practice Address - Phone:254-734-4254
Practice Address - Fax:254-734-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF35349Medicare UPIN