Provider Demographics
NPI:1821064528
Name:GUDAKUNST, CRAIG A (DO)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:GUDAKUNST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:B415 W FEE HALL
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-1315
Mailing Address - Country:US
Mailing Address - Phone:517-353-8470
Mailing Address - Fax:517-432-1074
Practice Address - Street 1:2720 S WASHINGTON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2800
Practice Address - Country:US
Practice Address - Phone:517-487-8255
Practice Address - Fax:517-487-2059
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008749L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1821064528Medicaid
PA0015577580004Medicaid
PA609520Medicare ID - Type Unspecified
PAA16864Medicare UPIN
MIC36082116Medicare PIN