Provider Demographics
NPI:1285610279
Name:BUNCH, LINDA C (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:C
Last Name:BUNCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 JUSTICE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3619
Mailing Address - Country:US
Mailing Address - Phone:318-388-0114
Mailing Address - Fax:318-388-0954
Practice Address - Street 1:2221 JUSTICE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3619
Practice Address - Country:US
Practice Address - Phone:318-388-0114
Practice Address - Fax:318-388-0954
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2012-02-06
Deactivation Date:2007-08-01
Deactivation Code:
Reactivation Date:2007-10-11
Provider Licenses
StateLicense IDTaxonomies
LA018178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1354708Medicaid
LA1354708Medicaid
LA52499Medicare ID - Type Unspecified
B63905Medicare UPIN
LA5896710001Medicare NSC