Provider Demographics
NPI:1740248962
Name:BRUNS, MARK D
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BRUNS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2625 E 62ND ST
Practice Address - Street 2:STE.2010
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2965
Practice Address - Country:US
Practice Address - Phone:317-251-6121
Practice Address - Fax:317-257-0390
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044194A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466450Medicaid
IN715530LLLMedicare PIN
INF93770Medicare UPIN
INP01107150Medicare PIN
INM400065180Medicare PIN