Basic Information
| Provider Information | |||||||||
| NPI: | 1821027210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNDY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MCCALL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUNDY | ||||||||
| OtherFirstName: | J | ||||||||
| OtherMiddleName: | MCCALL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 520 S MUSTANG RD | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730996737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365910 | ||||||||
| FaxNumber: | 4055772605 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 S MUSTANG RD | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365910 | ||||||||
| FaxNumber: | 4055772605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13740 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 13740 | 01 | OK | LICENSE | OTHER | 080047862 | 01 | OK | RAILROAD | OTHER | 14847 | 01 | OK | OBNDD | OTHER | 100152580A | 05 | OK | MEDICAID |