Provider Demographics
NPI:1043398605
Name:GUNN, EARLE WALCOTT III (MD)
Entity type:Individual
Prefix:DR
First Name:EARLE
Middle Name:WALCOTT
Last Name:GUNN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CODY
Other - Middle Name:
Other - Last Name:GUNN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3320 OLD JEFFERSON RD BLDG 800
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1400
Mailing Address - Country:US
Mailing Address - Phone:706-353-2990
Mailing Address - Fax:706-353-2992
Practice Address - Street 1:245 FLOYD DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1469
Practice Address - Country:US
Practice Address - Phone:762-356-4780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026538174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000365527OMedicaid
GA00365527CMedicaid
GAD45512Medicare UPIN