Provider Demographics
NPI:1083613046
Name:UNDERKOFLER, JANET (PA)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:UNDERKOFLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1594 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4546
Mailing Address - Country:US
Mailing Address - Phone:904-264-8621
Mailing Address - Fax:904-215-9418
Practice Address - Street 1:1594 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4546
Practice Address - Country:US
Practice Address - Phone:904-264-8621
Practice Address - Fax:904-215-9418
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0001744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002072500Medicaid
FLPA0001744OtherFL LICENSE
FL002072500Medicaid
FLRR P00709653Medicare PIN
FLD50294Medicare UPIN