MEDICARE: DR. DOUGLAS B BUNKER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	117535-2501	UT
2	103TH0100X	Health Service Psychologist	117535-2501	UT
3	103TA0400X	Addiction (Substance Use Disorder) Psychologist	117535-2501	UT

General Provider Information

NPI Number	:	1194789297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS B BUNKER PH.D.

Provider Business Mailing Address
First Line	:	1008 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-1548
Country	:	US
Telephone Number	:	801-583-7184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1008 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-1548
Country	:	US
Telephone Number	:	801-583-7184
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	04/26/2011

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