Provider Demographics
NPI:1801858576
Name:GUNN RUSSELL, IAN N (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:N
Last Name:GUNN RUSSELL
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Gender:M
Credentials:MD
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Mailing Address - Street 1:71 HANOVER RD
Mailing Address - Street 2:ADP MEDICAL DEPARTMENT
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1502
Mailing Address - Country:US
Mailing Address - Phone:973-712-3517
Mailing Address - Fax:973-712-3520
Practice Address - Street 1:71 HANOVER RD
Practice Address - Street 2:ADP MEDICAL DEPARTMENT
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1502
Practice Address - Country:US
Practice Address - Phone:973-712-3517
Practice Address - Fax:973-712-3520
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2012-06-12
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA03981600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1885201Medicaid
NJ1885201Medicaid
NJ590068Medicare PIN