Provider Demographics
NPI:1952390106
Name:GUNDERSEN, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:GUNDERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1216 RYANS RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1722
Mailing Address - Country:US
Mailing Address - Phone:507-372-2921
Mailing Address - Fax:507-372-6523
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-739-6742
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301069187207Q00000X
MN35677207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080093188OtherMETRAHEALTH
MI4540600Medicaid
MI5659321OtherAETNA
MI010G56026OtherHEALTH PLUS
MI0802502771OtherBLUE CROSS BLUE SHIELD
MI080D410020OtherBLUE CROSS BLUE SHIELD
MI204375OtherMCLAREN HEALTH PLAN
MIF31478OtherHEALTH NET FEDERAL
MI204375OtherHEALTH ADVANTAGE NETWORK
MIC4258OtherMCARE
MI080D410020OtherBLUE CARE NETWORK
MI7073962004OtherCIGNA
MIF31478OtherHEALTH ALLIANCE PLAN
MI0M28430051Medicare ID - Type Unspecified
MI010G56026OtherHEALTH PLUS
MIF31478OtherHEALTH ALLIANCE PLAN
MI204375OtherMCLAREN HEALTH PLAN