Provider Demographics
NPI:1558345124
Name:GUNN, ROGER A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:GUNN
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 1463
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-1463
Mailing Address - Country:US
Mailing Address - Phone:712-279-2372
Mailing Address - Fax:712-279-5631
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1394
Practice Address - Country:US
Practice Address - Phone:712-279-2372
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22334207ZP0105X
SD3935207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA23528OtherWELLMARK BLX
IN1035287Medicaid
SC0005660OtherWELLMARK BLX SD DUNES
IA0035287Medicaid
SD5660Medicare ID - Type Unspecified
IN1035287Medicaid
IA23528Medicare ID - Type Unspecified