Provider Demographics
NPI:1396704136
Name:BRUDNAK, DANIEL MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MICHAEL
Last Name:BRUDNAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:GORMAN
Mailing Address - State:TX
Mailing Address - Zip Code:76454-0417
Mailing Address - Country:US
Mailing Address - Phone:254-734-4254
Mailing Address - Fax:254-734-4355
Practice Address - Street 1:115 S KENT ST
Practice Address - Street 2:
Practice Address - City:GORMAN
Practice Address - State:TX
Practice Address - Zip Code:76454-3060
Practice Address - Country:US
Practice Address - Phone:254-734-4254
Practice Address - Fax:254-734-4355
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0041CWOtherBLUE CROSS
TX1365785-03Medicaid
TX1365785-03Medicaid
0041CWOtherBLUE CROSS