Provider Demographics
NPI:1861766321
Name:CLARK A GUNDERSON MD AMC
Entity type:Organization
Organization Name:CLARK A GUNDERSON MD AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUNDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-439-0385
Mailing Address - Street 1:2615 ENTERPRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7686
Mailing Address - Country:US
Mailing Address - Phone:337-439-0385
Mailing Address - Fax:337-433-5448
Practice Address - Street 1:2615 ENTERPRISE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7686
Practice Address - Country:US
Practice Address - Phone:337-439-0385
Practice Address - Fax:337-433-5448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0124589261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA114305Medicaid