Provider Demographics
NPI:1205931672
Name:BRULTE, MARK THOMAS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:BRULTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 DOCTORS DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2201
Mailing Address - Country:US
Mailing Address - Phone:912-384-3338
Mailing Address - Fax:912-389-0979
Practice Address - Street 1:200 DOCTORS DR
Practice Address - Street 2:SUITE 106
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2201
Practice Address - Country:US
Practice Address - Phone:912-384-3338
Practice Address - Fax:912-389-0979
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048490207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0008734441FMedicaid
GAGRP7301OtherMEDICARE GROUP #
GA000873441HMedicaid
GA478042OtherWELLCARE-DOUGLAS
GA543782OtherWELLCARE-NICHOLLS
GA000873441IMedicaid
GA00873441AMedicaid
GA541189OtherWELLCARE-WILLACOOCHEE
GA128214OtherPEACHSTATE
GA000873441HMedicaid
GA128214OtherPEACHSTATE
GAGRP7301OtherMEDICARE GROUP #