Healthcare Provider Details

I. General information

NPI: 1780105817
Provider Name (Legal Business Name): JOHN CHRISTEN BUNYASARANAND DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 EL SALVADOR WAY
EGLIN AFB FL
32542-1711
US

IV. Provider business mailing address

4315 EL SALVADOR WAY
EGLIN AFB FL
32542-1711
US

V. Phone/Fax

Practice location:
  • Phone: 850-885-9979
  • Fax:
Mailing address:
  • Phone: 850-885-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number2634
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO.2634
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS18810
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: