Provider Demographics
NPI:1558303404
Name:BRUNK, SHAWN K (DO)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:K
Last Name:BRUNK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:201 FIRST EXECUTIVE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1697
Mailing Address - Country:US
Mailing Address - Phone:636-441-3322
Mailing Address - Fax:636-441-4302
Practice Address - Street 1:201 FIRST EXECUTIVE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1697
Practice Address - Country:US
Practice Address - Phone:636-441-3322
Practice Address - Fax:636-441-4302
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9G74207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO002014242Medicare PIN
MOA11703Medicare UPIN
MOP00160727Medicare PIN