Provider Demographics
NPI:1336136712
Name:GUNDERSON, TODD CORY (OD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:CORY
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:CORY
Other - Last Name:GUNDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:255 W 36TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-7820
Mailing Address - Country:US
Mailing Address - Phone:812-481-2100
Mailing Address - Fax:812-481-2144
Practice Address - Street 1:255 W 36TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-7820
Practice Address - Country:US
Practice Address - Phone:812-481-2100
Practice Address - Fax:812-481-2144
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002006805152W00000X
IN18003376A152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U87534Medicare UPIN
ILL88873Medicare ID - Type Unspecified