1174565485 NPI number — ELAINE THERESE VAN GUNDY M.D., F.A.A.P.

Table of content: ELAINE THERESE VAN GUNDY M.D., F.A.A.P. (NPI 1174565485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174565485 NPI number — ELAINE THERESE VAN GUNDY M.D., F.A.A.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN GUNDY
Provider First Name:
ELAINE
Provider Middle Name:
THERESE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., F.A.A.P.
Provider Gender Code:
F

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:
1174565485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1451 SECRET RAVINE PKWY
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95661-4051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-580-2420
Provider Business Mailing Address Fax Number:
916-580-2402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1451 SECRET RAVINE PKWY
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-4051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-580-2420
Provider Business Practice Location Address Fax Number:
916-580-2402
Provider Enumeration Date:
06/12/2006

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: 174400000X , with the licence number:  C43153 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00C431530 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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