Healthcare Provider Details

I. General information

NPI: 1437152790
Provider Name (Legal Business Name): PETER F BRUNGARDT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 S OHIO ST
SALINA KS
67401-3177
US

IV. Provider business mailing address

436 S OHIO ST
SALINA KS
67401-3177
US

V. Phone/Fax

Practice location:
  • Phone: 785-825-0271
  • Fax: 785-825-0273
Mailing address:
  • Phone: 785-825-0271
  • Fax: 785-825-0273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1025-3
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: