Healthcare Provider Details

I. General information

NPI: 1679821284
Provider Name (Legal Business Name): BRIAN RUNDA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12981 S ORANGE BLOSSOM TRL
ORLANDO FL
32837-6592
US

IV. Provider business mailing address

2170 STERLING CREEK PKWY
OVIEDO FL
32766-8658
US

V. Phone/Fax

Practice location:
  • Phone: 407-816-5958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4712
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: