Provider Demographics
NPI:1013961242
Name:UNDESSER, KARL P (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:P
Last Name:UNDESSER
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:PO BOX 742941
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 FAIRVIEW AVE STE 230
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5432
Practice Address - Country:US
Practice Address - Phone:208-795-5073
Practice Address - Fax:208-402-3181
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6986207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1013961242Medicaid
ID20000107Medicare PIN
ID1013961242Medicaid