MEDICARE: CARSON GUNDLACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		NY

General Provider Information

NPI Number	:	1700735917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARSON GUNDLACH

Provider Business Mailing Address
First Line	:	420 E 70TH ST APT 13K3
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-5354
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 YORK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10065-4805
Country	:	US
Telephone Number	:	262-203-6505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2026
Last Update Date	:	01/22/2026

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Directions to “ CARSON GUNDLACH ” Practice Location

Language	Start Address	Practice Location

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