Provider Demographics
NPI:1013119734
Name:GUNDRUM, EDWARD EARL II (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:EARL
Last Name:GUNDRUM
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:ANESTHESIA DEPARTMENT
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-4574
Mailing Address - Fax:
Practice Address - Street 1:10950 CHURCH ST
Practice Address - Street 2:APT. 4423
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-8056
Practice Address - Country:US
Practice Address - Phone:909-941-9718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8979207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB213474Medicare PIN
CAFM511ZMedicare PIN