Provider Demographics
NPI:1063407732
Name:GUNTER, TRACY D (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:GUNTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:D
Other - Last Name:GUNTER-JUSTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-3834
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST
Practice Address - Street 2:SUITE 4800
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2207
Practice Address - Country:US
Practice Address - Phone:317-963-7288
Practice Address - Fax:317-963-7313
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080269182084P0800X
IA351392084P0800X
IN01070168A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201147280Medicaid
IA0294900Medicaid
IA34874OtherWELLMARK BCBS
INP01360488OtherRAILROAD MEDICARE
IAI9936Medicare PIN
IN116660002Medicare PIN
IA34874OtherWELLMARK BCBS
INP01360488OtherRAILROAD MEDICARE