Healthcare Provider Details

I. General information

NPI: 1265595615
Provider Name (Legal Business Name): KAREN WUNDERLICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 CORTEZ BLVD SUITE 102
BROOKSVILLE FL
34613-6056
US

IV. Provider business mailing address

14540 CORTEZ BLVD SUITE 102
BROOKSVILLE FL
34613-6056
US

V. Phone/Fax

Practice location:
  • Phone: 352-596-7255
  • Fax:
Mailing address:
  • Phone: 352-596-7255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME61722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: