Provider Demographics
NPI:1124220397
Name:GUNSBERGER, TANJA LEA (DO)
Entity Type:Individual
Prefix:
First Name:TANJA
Middle Name:LEA
Last Name:GUNSBERGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4668208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ307930Medicaid
AZ307930Medicaid
AZ120335Medicare PIN
AZ120687Medicare PIN