Provider Demographics
NPI:1518177740
Name:GUNN, MARTIN LAMAR
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:LAMAR
Last Name:GUNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3265
Mailing Address - Country:US
Mailing Address - Phone:843-545-9999
Mailing Address - Fax:843-545-1099
Practice Address - Street 1:605 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3265
Practice Address - Country:US
Practice Address - Phone:843-545-9999
Practice Address - Fax:843-545-1099
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCC157921744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1513Medicaid