Provider Demographics
NPI:1750318390
Name:VAN GUNDY, JEFF COULSTON (MD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:COULSTON
Last Name:VAN GUNDY
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 1:2516 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2208
Mailing Address - Country:US
Mailing Address - Phone:916-734-1461
Mailing Address - Fax:
Practice Address - Street 1:2521 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2207
Practice Address - Country:US
Practice Address - Phone:916-734-1461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC431542080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C431540Medicaid
CAE28103Medicare UPIN