Healthcare Provider Details

I. General information

NPI: 1275406605
Provider Name (Legal Business Name): ROBERT CHARLES BUNCE RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19331 SUSAN WAY
SONORA CA
95370-9209
US

IV. Provider business mailing address

19401 SUSAN WAY
SONORA CA
95370-9266
US

V. Phone/Fax

Practice location:
  • Phone: 209-588-7018
  • Fax:
Mailing address:
  • Phone: 209-588-7018
  • Fax: 209-396-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMSS-UWDAHL
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: