Provider Demographics
NPI:1992445001
Name:BRUNCKO, DOMINIQUE MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:MICHELLE
Last Name:BRUNCKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 COUNCIL CIR
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1648
Mailing Address - Country:US
Mailing Address - Phone:847-337-5134
Mailing Address - Fax:
Practice Address - Street 1:1 BAYLOR PLZ # BCM320
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3498
Practice Address - Country:US
Practice Address - Phone:832-824-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program