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General NPI Number Information
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NPI Number | 1952390106
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Entity Type | Individual
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Provider Name | MARK R GUNDERSEN MD
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Gender | Male
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Dates
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Enumeration Date | 10/20/2005
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Last Update Date | 10/29/2019
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Provider Practice Location Address
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Address Line | 712 SOUTH CASCADE STREET
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City | FERGUS FALLS
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State | MN
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Zip | 56537-2813
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Country | US
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Telephone | 218-736-8000
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Fax | 218-739-6742
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Provider Business Mailing Address
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Address Line | 1216 RYANS RD
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City | WORTHINGTON
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State | MN
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Zip | 56187-1722
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Country | US
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Telephone | 507-372-2921
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Fax | 507-372-6523
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301069187
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35677
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License Number State | MN
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