Healthcare Provider Details

I. General information

NPI: 1063407732
Provider Name (Legal Business Name): TRACY D GUNTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY D GUNTER-JUSTICE MD

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W 16TH ST SUITE 4800
INDIANAPOLIS IN
46202-2207
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-7288
  • Fax: 317-963-7313
Mailing address:
  • Phone: 317-962-3834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2008026918
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35139
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01070168A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: