Provider Demographics
NPI:1033103825
Name:LUNDERMAN, MAURI G (MD)
Entity Type:Individual
Prefix:MR
First Name:MAURI
Middle Name:G
Last Name:LUNDERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1775 LEWIS TURNER BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1221
Mailing Address - Country:US
Mailing Address - Phone:850-864-3232
Mailing Address - Fax:850-864-5220
Practice Address - Street 1:1775 LEWIS TURNER BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1221
Practice Address - Country:US
Practice Address - Phone:850-864-3232
Practice Address - Fax:850-864-5220
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME64728208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375781100Medicaid
FLF80420Medicare UPIN
FL375781100Medicaid