Provider Demographics
NPI:1679998223
Name:BRUNGO, JOHN DOMINIC (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOMINIC
Last Name:BRUNGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 INDEPENDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-3109
Mailing Address - Country:US
Mailing Address - Phone:412-366-7553
Mailing Address - Fax:
Practice Address - Street 1:155 INDEPENDENCE WAY
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-3109
Practice Address - Country:US
Practice Address - Phone:412-366-7553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012423E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine