Provider Demographics
NPI:1265420467
Name:BRUNSTON, ROBERT L JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:BRUNSTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1720A MEDICAL PARK DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2129
Mailing Address - Country:US
Mailing Address - Phone:228-396-1735
Mailing Address - Fax:228-396-1737
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUITE 180
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-396-1735
Practice Address - Fax:228-396-1737
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS17394208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124776Medicaid
02000430Medicare ID - Type Unspecified
H50384Medicare UPIN