Provider Demographics
NPI:1891895967
Name:BRUNELLE, RICHARD RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RAYMOND
Last Name:BRUNELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 S HABANA AVE
Mailing Address - Street 2:SUITE 370
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4181
Mailing Address - Country:US
Mailing Address - Phone:813-873-1850
Mailing Address - Fax:813-873-8046
Practice Address - Street 1:508 S HABANA AVE
Practice Address - Street 2:SUITE 370
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4181
Practice Address - Country:US
Practice Address - Phone:813-873-1850
Practice Address - Fax:813-873-8046
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25656174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0581887-00Medicaid
FLD58505Medicare UPIN
FL78471Medicare ID - Type Unspecified