Provider Demographics
NPI:1710989702
Name:AMUNDSEN, GERALD A II (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:AMUNDSEN
Suffix:II
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 1:206 N MUSTANG MALL TER
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-5135
Mailing Address - Country:US
Mailing Address - Phone:405-256-6000
Mailing Address - Fax:405-256-6001
Practice Address - Street 1:206 N MUSTANG MALL TER
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5135
Practice Address - Country:US
Practice Address - Phone:405-256-6000
Practice Address - Fax:405-256-6001
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100204570BMedicaid
OK200018240AMedicaid
OK200018240AMedicaid
OK100204570BMedicaid