Provider Demographics
NPI:1750327078
Name:SUNNER, GREGG S (OD)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:S
Last Name:SUNNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 NW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-1754
Mailing Address - Country:US
Mailing Address - Phone:515-964-7355
Mailing Address - Fax:515-964-8413
Practice Address - Street 1:111 NW 9TH ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1754
Practice Address - Country:US
Practice Address - Phone:515-964-7355
Practice Address - Fax:515-964-8413
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0142919Medicaid
IAT00868Medicare UPIN
IA02890Medicare ID - Type Unspecified