Provider Demographics
NPI:1952326613
Name:BRUNSON, SANDRA CULLEN (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:CULLEN
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 LAKEVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:516-437-4098
Mailing Address - Fax:516-352-6579
Practice Address - Street 1:2035 LAKEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:516-437-4098
Practice Address - Fax:516-352-6579
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124295208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01262115Medicaid
F36069Medicare UPIN
NY01262115Medicaid