Healthcare Provider Details

I. General information

NPI: 1700885068
Provider Name (Legal Business Name): STANLEY BRULL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VILLAGE SQ SUITE #190
BALTIMORE MD
21210-1602
US

IV. Provider business mailing address

1 VILLAGE SQ STE 190
BALTIMORE MD
21210-1605
US

V. Phone/Fax

Practice location:
  • Phone: 410-435-8881
  • Fax: 410-435-8886
Mailing address:
  • Phone: 410-821-6400
  • Fax: 410-296-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0002515
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: