Basic Information
Provider Information | |||||||||
NPI: | 1467911602 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRUNELLO | ||||||||
FirstName: | DOMINIC | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 SCHERMERHORN ST APT 815 | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112015898 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054781607 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 234 E 149TH ST | ||||||||
Address2: |   | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104515504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7185796011 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2019 | ||||||||
LastUpdateDate: | 03/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.