Provider Demographics
NPI:1013903731
Name:BRUGMAN, RICHARD DEREK (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DEREK
Last Name:BRUGMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2907 ROUSSEAU CT
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2103
Mailing Address - Country:US
Mailing Address - Phone:980-421-7021
Mailing Address - Fax:980-407-5757
Practice Address - Street 1:2907 ROUSSEAU CT
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2103
Practice Address - Country:US
Practice Address - Phone:980-421-7021
Practice Address - Fax:980-407-5757
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601252208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01252Medicaid
NC8919288Medicaid
NCF77471Medicare UPIN