Provider Demographics
NPI:1316200215
Name:UNDERKOFLER, HEATHER A (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:A
Last Name:UNDERKOFLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:7322 W RAWSON AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8104
Practice Address - Country:US
Practice Address - Phone:414-433-9010
Practice Address - Fax:414-433-9007
Is Sole Proprietor?:No
Enumeration Date:2012-06-17
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020904208000000X
CAA135678208000000X
WI65619-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316200215Medicaid