MEDICARE: DR. ERIC M GUDAN PSYD

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	103TC0700X	Clinical Psychologist	20042547A	IN

General Provider Information

NPI Number	:	1861624736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC M GUDAN PSYD

Provider Business Mailing Address
First Line	:	6239 S EAST ST
Second Line	:	SUITE E
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-2090
Country	:	US
Telephone Number	:	317-455-6780
Fax Number	:

Provider Business Practice Location Address
First Line	:	6239 S EAST ST
Second Line	:	SUITE E
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-2090
Country	:	US
Telephone Number	:	317-455-6780
Fax Number	:

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

Provider Enumeration Date	:	08/11/2009
Last Update Date	:	09/20/2011

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