Healthcare Provider Details

I. General information

NPI: 1568501575
Provider Name (Legal Business Name): JEFFREY TODD BUNNING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR STE 270
GASTONIA NC
28054-2185
US

IV. Provider business mailing address

PO BOX 741087
ATLANTA GA
30374-1087
US

V. Phone/Fax

Practice location:
  • Phone: 704-671-5313
  • Fax:
Mailing address:
  • Phone: 954-507-6780
  • Fax: 866-262-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number2023-00754
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME161657
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2023-00754
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: