Provider Demographics
NPI:1972524403
Name:KOCHENDORFER, KARL M (MD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:M
Last Name:KOCHENDORFER
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 1:720 W MAXWELL ST FL 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-5017
Mailing Address - Country:US
Mailing Address - Phone:312-996-2901
Mailing Address - Fax:
Practice Address - Street 1:720 W MAXWELL ST FL 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-5017
Practice Address - Country:US
Practice Address - Phone:312-996-2901
Practice Address - Fax:312-413-2364
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018405207Q00000X
IL036-114345207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO757339OtherHEALTHLINK
MO205456700Medicaid
MOP00430568Medicare PIN
MO205456700Medicaid
MO959915236Medicare PIN
MO959911950Medicare PIN