MEDICARE: DR. GERALD FRANK BUNTING-BLAKE M.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	207Q00000X	Family Medicine Physician	31378	AZ
2	207Q00000X	Family Medicine Physician	13051	NE
3	2084P0800X	Psychiatry Physician	31378	AZ
4	2084P0800X	Psychiatry Physician	13051	NE

General Provider Information

NPI Number	:	1417934662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD FRANK BUNTING-BLAKE M.D.

Provider Business Mailing Address
First Line	:	2125 E GOLF AVE
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-4031
Country	:	US
Telephone Number	:	480-201-0781
Fax Number	:

Provider Business Practice Location Address
First Line	:	5380 E KACHINA ST
Second Line	:
City	:	DAVIS MONTHAN A F B
State	:	AZ
Zip	:	85707-4923
Country	:	US
Telephone Number	:	520-228-4926
Fax Number	:

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	11/15/2007

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