MEDICARE: GERALD A AMUNDSEN II MD

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	207Q00000X	Family Medicine Physician	20242	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710989702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD A AMUNDSEN II MD

Provider Business Mailing Address
First Line	:	206 N MUSTANG MALL TER
Second Line	:
City	:	MUSTANG
State	:	OK
Zip	:	73064-5135
Country	:	US
Telephone Number	:	405-256-6000
Fax Number	:	405-256-6001

Provider Business Practice Location Address
First Line	:	206 N MUSTANG MALL TER
Second Line	:
City	:	MUSTANG
State	:	OK
Zip	:	73064-5135
Country	:	US
Telephone Number	:	405-256-6000
Fax Number	:	405-256-6001

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	05/23/2012

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