Provider Demographics
NPI:1568730026
Name:GUNDERSON, MARK TRAVIS (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TRAVIS
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 15TH ST S STE C
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6188
Mailing Address - Country:US
Mailing Address - Phone:701-451-9070
Mailing Address - Fax:
Practice Address - Street 1:3240 15TH ST S STE C
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6188
Practice Address - Country:US
Practice Address - Phone:701-451-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND895111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor