Provider Demographics
NPI:1346224649
Name:SUNADA, GARY MASAO (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MASAO
Last Name:SUNADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1750
Practice Address - Fax:574-647-1748
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01030005A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN247000005OtherMEDICARE PTAN
IN100358940Medicaid
IN247000005OtherMEDICARE PTAN
IN169380OMedicare PIN
INE21272Medicare UPIN
IN565800WMedicare PIN