Provider Demographics
NPI:1003964248
Name:GUNDLACH, ROGER OSCAR (DC,)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:OSCAR
Last Name:GUNDLACH
Suffix:
Gender:M
Credentials:DC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 RUSSELL DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-1066
Mailing Address - Country:US
Mailing Address - Phone:920-748-7122
Mailing Address - Fax:
Practice Address - Street 1:315 MOUNT ZION DR
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-1713
Practice Address - Country:US
Practice Address - Phone:920-745-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2307-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38842600Medicaid
WI75952Medicare ID - Type Unspecified
WI38842600Medicaid