Provider Demographics
NPI:1487697348
Name:BRUNOT, MARK DOUGLAS (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:BRUNOT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-1761
Mailing Address - Country:US
Mailing Address - Phone:814-827-7965
Mailing Address - Fax:814-827-7945
Practice Address - Street 1:120 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1761
Practice Address - Country:US
Practice Address - Phone:814-827-7965
Practice Address - Fax:814-827-7945
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007732L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA211508OtherUPMC
PABR828150OtherBC/BS
PA1897579OtherFIRST HEALTH
PA409737OtherHEALTH AMERICA
PA001764520001Medicaid
PAMA860738OtherBC/BS
PAR11191240OtherMULTIPLAN
PA000000117781OtherUNISON
PA8687183OtherCIGNA
PA037131Medicare ID - Type Unspecified
PA001764520001Medicaid