1295898666 NPI number — DR. MATTHEW FREDERICK GUNDLACH EDD

Table of content: DR. MATTHEW FREDERICK GUNDLACH EDD (NPI 1295898666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295898666 NPI number — DR. MATTHEW FREDERICK GUNDLACH EDD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNDLACH
Provider First Name:
MATTHEW
Provider Middle Name:
FREDERICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
EDD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295898666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12450 WAYZATA BLVD
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55305-1978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-545-0110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12450 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-1978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-545-0110
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  LP1055 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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