Provider Demographics
NPI:1013913011
Name:BUNNER, JULIE SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:SUZANNE
Last Name:BUNNER
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 1:58 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3660
Mailing Address - Country:US
Mailing Address - Phone:304-243-6410
Mailing Address - Fax:304-243-6411
Practice Address - Street 1:58 16TH ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3660
Practice Address - Country:US
Practice Address - Phone:304-243-6410
Practice Address - Fax:304-243-6411
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19765207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2325353Medicaid
WV55035705701OtherWV COMPENSATION
001718176OtherMOUNTAIN STATE BCBS
19765OtherHEALTH PLAN OF UPPER OH V
WV1812151000Medicaid
WV1812151000Medicaid
WV55035705701OtherWV COMPENSATION
H57848Medicare UPIN