Provider Demographics
NPI:1023497740
Name:BRUNI, LARRY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:MICHAEL
Last Name:BRUNI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:370 PARTRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2939
Mailing Address - Country:US
Mailing Address - Phone:518-812-4899
Mailing Address - Fax:
Practice Address - Street 1:1 PINNACLE PL
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3496
Practice Address - Country:US
Practice Address - Phone:518-360-1011
Practice Address - Fax:518-278-4417
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275946207R00000X
VA0101-037258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101-037258OtherMEDICAL LICENSE
NY275946OtherMEDICAL LICENSE
XB5078236OtherDATA 2000 WAIVER