Provider Demographics
NPI:1457382764
Name:BRUNGARDT, GERARD S (MD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:S
Last Name:BRUNGARDT
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 1358
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1358
Mailing Address - Country:US
Mailing Address - Phone:316-293-3429
Mailing Address - Fax:316-293-1882
Practice Address - Street 1:8533 E 32ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2611
Practice Address - Country:US
Practice Address - Phone:316-293-2622
Practice Address - Fax:855-517-9494
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-20542207RG0300X, 207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004372270003Medicaid