Provider Demographics
NPI:1306822739
Name:WUNDER, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:WUNDER
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:PO BOX 51030
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0018
Mailing Address - Country:US
Mailing Address - Phone:843-238-8660
Mailing Address - Fax:
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-238-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-18
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC188122085R0202X, 2085R0204X, 2085B0100X, 2085D0003X, 2085U0001X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0001X, 2085R0205X, 2085R0203X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG15125Medicare UPIN