Provider Demographics
NPI:1417993098
Name:GUNDERSEN, DAVID M (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:GUNDERSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 W WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49440
Mailing Address - Country:US
Mailing Address - Phone:231-722-3556
Mailing Address - Fax:231-726-6334
Practice Address - Street 1:442 W WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49440
Practice Address - Country:US
Practice Address - Phone:231-722-3556
Practice Address - Fax:231-726-6334
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDG002694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336362383OtherNPI MONTAGUE DME
1942385265OtherNPI MONTAGUE
MI1764566Medicaid
1467675405OtherNPI MUSKEGON DME
1831270891OtherNPI MUSKEGON
MI5102139Medicaid
1033294350OtherNPI SHELBY
MI5082457Medicaid
1427271477OtherNPI SHELBY DME
1942385265OtherNPI MONTAGUE
1336362383OtherNPI MONTAGUE DME
MI5102139Medicaid
MI5082457Medicaid
MI0809120001Medicare NSC