Healthcare Provider Details

I. General information

NPI: 1881449635
Provider Name (Legal Business Name): GAGE JAMES BUNESS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269-1099
US

IV. Provider business mailing address

3504 E CLAREMONT AVE
PARADISE VALLEY AZ
85253-3749
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7880
  • Fax:
Mailing address:
  • Phone: 602-448-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.086678
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: