Provider Demographics
NPI:1598784621
Name:BUNDGARD, PETER ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ANDREW
Last Name:BUNDGARD
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 940
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39190-0940
Mailing Address - Country:US
Mailing Address - Phone:601-446-6899
Mailing Address - Fax:601-304-9714
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:WALTHALL COUNTY GENERAL HOSPITAL
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2022
Practice Address - Country:US
Practice Address - Phone:601-876-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15002207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0117315Medicaid
MS0117315Medicaid