Provider Demographics
NPI:1689808123
Name:PERSAVICH, KATHLEEN WUNDER (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:WUNDER
Last Name:PERSAVICH
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-3000
Mailing Address - Fax:704-316-3001
Practice Address - Street 1:2400 SOUTH BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5773
Practice Address - Country:US
Practice Address - Phone:704-316-3000
Practice Address - Fax:704-316-3001
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC157376207V00000X
NC2013-00887207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1689808123Medicaid
NCNCD198AMedicare PIN