Provider Demographics
NPI:1528556792
Name:BRUNSON, DANA JAE SMITH (MD)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:JAE SMITH
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:JAE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-988-5281
Practice Address - Fax:601-974-6241
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28982207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine