Provider Demographics
NPI:1851592067
Name:GUNN, MONTOYA DEMONT (IDC)
Entity Type:Individual
Prefix:
First Name:MONTOYA
Middle Name:DEMONT
Last Name:GUNN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-4820
Mailing Address - Country:US
Mailing Address - Phone:910-389-6914
Mailing Address - Fax:
Practice Address - Street 1:1801 FULLER RD
Practice Address - Street 2:SUITE A-01
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39309-5106
Practice Address - Country:US
Practice Address - Phone:601-679-3973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman