Provider Demographics
NPI:1891865168
Name:GUNDERSON, GLEN ARTHUR (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ARTHUR
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8836 AUBURN WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5111 ERHLICH ROAD
Practice Address - Street 2:SUITE 128
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624
Practice Address - Country:US
Practice Address - Phone:813-960-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU64842Medicare UPIN