MEDICARE: DANTE DE LOS SANTOS BRUNO MD

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	208D00000X	General Practice Physician	53781	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	324615	OTHER	VA	BCBS

General Provider Information

NPI Number	:	1700886298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANTE DE LOS SANTOS BRUNO MD

Provider Business Mailing Address
First Line	:	1020 BILL TUCK HWY
Second Line	:	STE 900
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-7136
Country	:	US
Telephone Number	:	484-575-7555
Fax Number	:	484-575-5556

Provider Business Practice Location Address
First Line	:	1020 BILL TUCK HWY
Second Line	:	STE 900
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-7136
Country	:	US
Telephone Number	:	484-575-7555
Fax Number	:	484-575-5556

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/07/2010

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