Healthcare Provider Details

I. General information

NPI: 1013979699
Provider Name (Legal Business Name): CARL V BUNDSCHUH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MAR LEN DR
MELBOURNE BEACH FL
32951-3122
US

IV. Provider business mailing address

11995 SINGLETREE LN SUITE 500
EDEN PRAIRIE MN
55344-5347
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 952-595-1301
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101039192
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME83220
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: