Provider Demographics
NPI:1255758793
Name:GUNNELL, PHILLIP BROWN (DO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BROWN
Last Name:GUNNELL
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 1:35709 GRENNADA ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5239
Mailing Address - Country:US
Mailing Address - Phone:480-316-9352
Mailing Address - Fax:
Practice Address - Street 1:1350 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2400
Practice Address - Country:US
Practice Address - Phone:435-752-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-22
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021267390200000X
MI5315066358390200000X
UT10588322-12042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program