Provider Demographics
NPI:1003412198
Name:GURUNG, DEEPAK
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:GURUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S MORRISON RD APT 44
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4009
Mailing Address - Country:US
Mailing Address - Phone:501-513-7309
Mailing Address - Fax:
Practice Address - Street 1:2200 W WHITE RIVER BLVD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-5242
Practice Address - Country:US
Practice Address - Phone:501-513-7309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012564A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist