Provider Demographics
NPI:1861620098
Name:GUNDERSON, SCOTT NOAL (OD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:NOAL
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3454 MOLLY LN
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-4519
Mailing Address - Country:US
Mailing Address - Phone:801-836-5350
Mailing Address - Fax:
Practice Address - Street 1:5760 W 120TH AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-6942
Practice Address - Country:US
Practice Address - Phone:303-951-1820
Practice Address - Fax:303-951-1826
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist