Provider Demographics
NPI:1053488353
Name:BRUNVOLL, GARY A (DO)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:A
Last Name:BRUNVOLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21709
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37424-0709
Mailing Address - Country:US
Mailing Address - Phone:423-648-6020
Mailing Address - Fax:423-648-6025
Practice Address - Street 1:7490 ZIEGLER RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3156
Practice Address - Country:US
Practice Address - Phone:423-648-6020
Practice Address - Fax:423-648-6025
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000001147207V00000X
TND0001147207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3802626Medicaid
TN1531973Medicaid
TN3802626Medicaid
TN1531973Medicaid