Provider Demographics
NPI:1104355387
Name:GUNAWAN, FERRY (MD)
Entity type:Individual
Prefix:
First Name:FERRY
Middle Name:
Last Name:GUNAWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9576 HWY 70
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9067
Mailing Address - Country:US
Mailing Address - Phone:715-358-1000
Mailing Address - Fax:715-358-1156
Practice Address - Street 1:9576 HWY 70
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9067
Practice Address - Country:US
Practice Address - Phone:715-358-1000
Practice Address - Fax:715-358-1156
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73021-20208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist