Healthcare Provider Details

I. General information

NPI: 1083935498
Provider Name (Legal Business Name): DAVID W BROUNLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 07/14/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MADISON AVE
COVINGTON KY
41011-3313
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-655-6100
  • Fax:
Mailing address:
  • Phone: 513-585-5505
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35027547
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberTP277
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: