Provider Demographics
NPI:1487765301
Name:GUNNELL, JOHN C
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:GUNNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 ARDEN AVE STE 520
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1138
Mailing Address - Country:US
Mailing Address - Phone:818-247-5440
Mailing Address - Fax:
Practice Address - Street 1:435 ARDEN AVE STE 520
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-247-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17573207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G175730Medicaid
CAWG17573FMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL#
CA00G175730Medicaid