Healthcare Provider Details

I. General information

NPI: 1457921272
Provider Name (Legal Business Name): BRANT GUNDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N WASHINGTON AVE STE 150
COOKEVILLE TN
38501-2623
US

IV. Provider business mailing address

PO BOX 306556
NASHVILLE TN
37230-6556
US

V. Phone/Fax

Practice location:
  • Phone: 931-525-6676
  • Fax: 931-525-6689
Mailing address:
  • Phone: 615-329-2294
  • Fax: 615-695-1494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number74455
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: