Provider Demographics
NPI:1740242502
Name:GUNDERSON, PAUL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THOMAS
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1293 E PARKDALE AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-8904
Mailing Address - Country:US
Mailing Address - Phone:231-398-1710
Mailing Address - Fax:231-398-1716
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8904
Practice Address - Country:US
Practice Address - Phone:231-398-1710
Practice Address - Fax:231-398-1716
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIPG038176208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1749425Medicaid