Basic Information
| Provider Information | |||||||||
| NPI: | 1558398156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WUNDER | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17364 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802170364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4251 KIPLING ST | ||||||||
| Address2: | STE 220 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034238334 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208100000X | 27646 | CO | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 10390870 | 05 | CO | MEDICAID |