Healthcare Provider Details

I. General information

NPI: 1548216419
Provider Name (Legal Business Name): KIMBERLY ANN BRUNO-DE LA MATA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13506 SUMMERPORT VILLAGE PKWY #341
WINDERMERE FL
34786-7366
US

IV. Provider business mailing address

1200 J D ANDERSON DR
MORGANTOWN WV
26505-3494
US

V. Phone/Fax

Practice location:
  • Phone: 865-363-3330
  • Fax:
Mailing address:
  • Phone: 304-598-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME101735
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: