Healthcare Provider Details

I. General information

NPI: 1972443331
Provider Name (Legal Business Name): GUNNAR LAVAUR JEPPSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2026
Last Update Date: 03/28/2026
Certification Date: 03/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

1013 BURRELL AVE APT 7
LEWISTON ID
83501-5591
US

V. Phone/Fax

Practice location:
  • Phone: 843-234-7405
  • Fax:
Mailing address:
  • Phone: 208-816-9819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: