Healthcare Provider Details

I. General information

NPI: 1609968346
Provider Name (Legal Business Name): ALEXANDRA R. BUNYAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N. EL CAMINO REAL STE 504
ENCINITAS CA
92024-2815
US

IV. Provider business mailing address

317 N. EL CAMINO REAL STE 504
ENCINITAS CA
92024-2815
US

V. Phone/Fax

Practice location:
  • Phone: 760-632-1090
  • Fax: 760-652-4825
Mailing address:
  • Phone: 760-632-1090
  • Fax: 760-652-4825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA78808
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03-0431018
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerTRICARE
# 2
IdentifierZZZ04918Z
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerBLU SHIELD
# 3
IdentifierGR0093170
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: