Provider Demographics
NPI:1508113168
Name:GUNN, SUSAN SULLIVAN (M D)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:SULLIVAN
Last Name:GUNN
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 LYLES DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5708
Mailing Address - Country:US
Mailing Address - Phone:662-513-4599
Mailing Address - Fax:
Practice Address - Street 1:400 REBEL DRIVE
Practice Address - Street 2:
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-7274
Practice Address - Fax:662-915-5292
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSG52554Medicare UPIN