Healthcare Provider Details

I. General information

NPI: 1861421406
Provider Name (Legal Business Name): JONATHAN J BRUNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HIGHWAY 16 E
CARTHAGE MS
39051-4222
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-267-1470
  • Fax: 601-267-1469
Mailing address:
  • Phone: 901-227-3255
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number19353
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: