Provider Demographics
NPI:1245270552
Name:BRUNICARDI, MARIO O (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:O
Last Name:BRUNICARDI
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:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 OHIOHEALTH WAY FL 2
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-9253
Practice Address - Country:US
Practice Address - Phone:567-309-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-070975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHG63943Medicare UPIN
OH2095969Medicare ID - Type Unspecified
OHBR0841671Medicare ID - Type Unspecified