Healthcare Provider Details

I. General information

NPI: 1316033350
Provider Name (Legal Business Name): ERIK WILLIAM GUNDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 E HIGH STREET CENTER FOR WELLNESS AND CHANGE, LLC
CHARLOTTESVILLE VA
22902
US

IV. Provider business mailing address

1702 YORKTOWN DRIVE
CHARLOTTESVILLE VA
22901
US

V. Phone/Fax

Practice location:
  • Phone: 434-202-8612
  • Fax: 434-321-5181
Mailing address:
  • Phone: 434-202-8612
  • Fax: 434-321-5181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number212008
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101244180
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number0101244180
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: