Provider Demographics
NPI:1003889924
Name:GUNDECK, ETHAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:L
Last Name:GUNDECK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1 COLUMBIA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-3923
Mailing Address - Country:US
Mailing Address - Phone:845-473-1188
Mailing Address - Fax:845-473-0896
Practice Address - Street 1:200 WESTAGE BUSINESS CTR
Practice Address - Street 2:SUITE 111
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524
Practice Address - Country:US
Practice Address - Phone:845-897-9760
Practice Address - Fax:845-896-3602
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2018-09-07
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Provider Licenses
StateLicense IDTaxonomies
NY235596207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02668160Medicaid
NY02668160Medicaid
NY632P31Medicare UPIN