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General NPI Number Information
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NPI Number | 1275835274
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Entity Type | Organization
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Legal Business Name | JOHN T GUDMUNDSON
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Dates
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Enumeration Date | 11/23/2010
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Last Update Date | 11/23/2010
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Provider Practice Location Address
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Address Line | 13455 MANCHESTER RD
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City | DES PERES
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State | MO
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Zip | 63131-1711
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Country | US
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Telephone | 314-822-4423
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Fax | 314-822-5541
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Provider Business Mailing Address
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Address Line | 901 E 3RD ST
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City | WASHINGTON
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State | MO
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Zip | 63090-3010
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Country | US
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Telephone | 636-390-3999
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Fax | 636-390-3959
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. JOHN T GUDMUNDSON
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Credential | OD
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Telephone | 636-390-3999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | T02992
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License Number State | MO
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