Provider Demographics
NPI:1043284581
Name:UNDERDAHL, JERALD P (MD)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:P
Last Name:UNDERDAHL
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:PO BOX 97876
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-7876
Mailing Address - Country:US
Mailing Address - Phone:602-222-2234
Mailing Address - Fax:866-985-7247
Practice Address - Street 1:1331 N 7TH ST
Practice Address - Street 2:100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2754
Practice Address - Country:US
Practice Address - Phone:602-222-2234
Practice Address - Fax:866-985-7247
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28541207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ524513Medicaid
83040Medicare ID - Type Unspecified
G98646Medicare UPIN