=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659384667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERALD A BRUNDAGE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2625 W ALAMEDA AVE SUITE 110
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-843-8616
-----------------------------------------------------
Fax | 818-845-2119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1970 STARVALE RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91207-1050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-843-8616
-----------------------------------------------------
Fax | 818-845-2119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | C34743
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------