Provider Demographics
NPI:1841501731
Name:GUNDERSEN, JASON BILL (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:BILL
Last Name:GUNDERSEN
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 1:3450 POTOMAC WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4970
Mailing Address - Country:US
Mailing Address - Phone:208-557-2900
Mailing Address - Fax:208-557-2910
Practice Address - Street 1:3450 POTOMAC WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4970
Practice Address - Country:US
Practice Address - Phone:208-557-2900
Practice Address - Fax:208-557-2910
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12486207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1841501731Medicaid