Provider Demographics
NPI:1699886309
Name:GUNBY, MARK C (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:GUNBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3844 S LINDBERGH BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1369
Mailing Address - Country:US
Mailing Address - Phone:314-525-0490
Mailing Address - Fax:
Practice Address - Street 1:3844 S LINDBERGH BLVD STE 120
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1369
Practice Address - Country:US
Practice Address - Phone:314-525-0490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100326207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO243773900Medicaid
MO01201878Medicare ID - Type Unspecified
MO243773900Medicaid