Provider Demographics
NPI:1801979828
Name:BRUNNER, ROBERT JERRY (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JERRY
Last Name:BRUNNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3003 NEW HYDE PARK ROAD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1214
Mailing Address - Country:US
Mailing Address - Phone:516-352-0022
Mailing Address - Fax:516-352-0407
Practice Address - Street 1:3003 NEW HYDE PARK ROAD
Practice Address - Street 2:SUITE 306
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1214
Practice Address - Country:US
Practice Address - Phone:516-352-0022
Practice Address - Fax:516-352-0407
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220901207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400086365Medicare PIN
NYWXQRP1Medicare UPIN