Provider Demographics
NPI:1902839798
Name:MAURI G LUNDERMAN, M.D., P.A.
Entity Type:Organization
Organization Name:MAURI G LUNDERMAN, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURI
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:LUNDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-864-3232
Mailing Address - Street 1:1775 LEWIS TURNER BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1221
Mailing Address - Country:US
Mailing Address - Phone:850-864-3232
Mailing Address - Fax:850-864-5220
Practice Address - Street 1:1775 LEWIS TURNER BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1221
Practice Address - Country:US
Practice Address - Phone:850-864-3232
Practice Address - Fax:850-864-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64728208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375781100Medicaid
FL375781100Medicaid