Provider Demographics
NPI:1689363095
Name:CUNHA DE MEDEIROS, BRUNO
Entity type:Individual
Prefix:
First Name:BRUNO
Middle Name:
Last Name:CUNHA DE MEDEIROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR.
Mailing Address - Street 2:H1302F
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305
Mailing Address - Country:US
Mailing Address - Phone:650-736-1227
Mailing Address - Fax:650-497-0405
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-4036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2025-06-11
Deactivation Date:2023-12-07
Deactivation Code:
Reactivation Date:2025-03-03
Provider Licenses
StateLicense IDTaxonomies
TX486552085R0202X, 2085P0229X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program