Provider Demographics
NPI:1174565485
Name:VAN GUNDY, ELAINE THERESE (MD, FAAP)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:THERESE
Last Name:VAN GUNDY
Suffix:
Gender:F
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 SECRET RAVINE PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4051
Mailing Address - Country:US
Mailing Address - Phone:916-580-2420
Mailing Address - Fax:916-580-2402
Practice Address - Street 1:1451 SECRET RAVINE PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4051
Practice Address - Country:US
Practice Address - Phone:916-580-2420
Practice Address - Fax:916-580-2402
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43153174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C431530Medicaid
CAE29166Medicare UPIN