Basic Information
| Provider Information | |||||||||
| NPI: | 1003889924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUNDECK | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 COLUMBIA ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454731188 | ||||||||
| FaxNumber: | 8454730896 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 WESTAGE BUSINESS CTR | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | FISHKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458979760 | ||||||||
| FaxNumber: | 8458963602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | 235596 | NY | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | 235596 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 02668160 | 05 | NY | MEDICAID |