Provider Demographics
NPI:1467656926
Name:GUDJONSSON, ULFUR T (MD)
Entity Type:Individual
Prefix:
First Name:ULFUR
Middle Name:T
Last Name:GUDJONSSON
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 1:10330 N MERIDIAN ST # 300
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 SAINT MARYS DR STE 300
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0521
Practice Address - Country:US
Practice Address - Phone:812-473-2642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126528208G00000X, 208G00000X
IN01070481A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017214900Medicaid
FLIO374ZMedicare PIN
INP01054244Medicare PIN
IN201052570Medicaid
FL017214900Medicaid
GA78BBBGWMedicare PIN
FLIO374ZMedicare PIN