Provider Demographics
NPI:1336150739
Name:BUNZ, BRENT C (DO)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:C
Last Name:BUNZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:11111 S 84TH ST
Practice Address - Street 2:ER DEPT
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-4122
Practice Address - Country:US
Practice Address - Phone:402-593-3550
Practice Address - Fax:937-619-4150
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE314208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE35754OtherBCBS
NE35754OtherBCBS
H24161Medicare UPIN
930116752Medicare PIN
NE275307Medicare PIN