Provider Demographics
NPI:1457410672
Name:GUNDERSON, CHARLISE A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLISE
Middle Name:A
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:555 E MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4367
Mailing Address - Country:US
Mailing Address - Phone:281-488-4477
Mailing Address - Fax:281-480-1623
Practice Address - Street 1:555 E MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4367
Practice Address - Country:US
Practice Address - Phone:281-488-4477
Practice Address - Fax:281-480-1623
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ3316207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132654808Medicaid
TXG09984Medicare UPIN
TX132654808Medicaid