Provider Demographics
NPI:1043205404
Name:BIRKEDAL, CHRISTIAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:L
Last Name:BIRKEDAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5168
Mailing Address - Country:US
Mailing Address - Phone:386-231-3530
Mailing Address - Fax:386-231-3534
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5168
Practice Address - Country:US
Practice Address - Phone:386-231-3530
Practice Address - Fax:386-231-3534
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84422208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263857600Medicaid
FLE7365Medicare ID - Type Unspecified
FL263857600Medicaid