Basic Information
Provider Information | |||||||||
NPI: | 1770512089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUNNELL | ||||||||
FirstName: | EUGENE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 56 FRANKLIN ST | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067061221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037098873 | ||||||||
FaxNumber: | 2037098689 | ||||||||
Practice Location | |||||||||
Address1: | 30 PROSPECT AVE | ||||||||
Address2: |   | ||||||||
City: | HACKENSACK | ||||||||
State: | NJ | ||||||||
PostalCode: | 076011915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5519964838 | ||||||||
FaxNumber: | 5519963984 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2006 | ||||||||
LastUpdateDate: | 09/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 037181 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 037181 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 25MA09546600 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 25MA09546600 | NJ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 001371814 | 05 | CT |   | MEDICAID | 0440469 | 05 | NJ |   | MEDICAID |