Provider Demographics
NPI:1306112362
Name:JAMES E BRUNS OD A PROFESSIONAL
Entity type:Organization
Organization Name:JAMES E BRUNS OD A PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BORDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-584-7294
Mailing Address - Street 1:6180 STATE FARM DR
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2135
Mailing Address - Country:US
Mailing Address - Phone:707-584-7294
Mailing Address - Fax:707-584-4728
Practice Address - Street 1:6180 STATE FARM DR
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2135
Practice Address - Country:US
Practice Address - Phone:707-584-7294
Practice Address - Fax:707-584-4728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA5247305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0052470Medicaid
TO9917Medicare UPIN
CASD0052470Medicaid