Provider Demographics
NPI:1083831887
Name:GUNDERSON, CLARK A (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:A
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2146
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-2146
Mailing Address - Country:US
Mailing Address - Phone:337-439-0385
Mailing Address - Fax:337-433-5448
Practice Address - Street 1:1717 OAK PARK BLVD FL 3
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8990
Practice Address - Country:US
Practice Address - Phone:337-439-0385
Practice Address - Fax:337-433-5448
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12489207X00000X
261Q00000X
LA012489207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1861766321OtherNPPES
LA1141305Medicaid
LA3073307Medicaid
LA1141305Medicaid