Provider Demographics
NPI:1063477677
Name:KUNDLAS, GURDEEP S (MD)
Entity Type:Individual
Prefix:
First Name:GURDEEP
Middle Name:S
Last Name:KUNDLAS
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 1:7569 STATE ROUTE 54
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-9533
Mailing Address - Country:US
Mailing Address - Phone:607-776-2932
Mailing Address - Fax:607-776-3640
Practice Address - Street 1:7569 STATE ROUTE 54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-9533
Practice Address - Country:US
Practice Address - Phone:607-776-2932
Practice Address - Fax:607-776-3640
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01761751Medicaid
NY000013534OtherBC BS CENTRAL NEW YORK
NYBB1000Medicare ID - Type Unspecified
NY01761751Medicaid