Provider Demographics
NPI:1134164106
Name:UNDERWOOD, ANTHONY L (DO)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:L
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 3RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-5109
Mailing Address - Country:US
Mailing Address - Phone:904-270-0767
Mailing Address - Fax:904-694-0058
Practice Address - Street 1:320 3RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5109
Practice Address - Country:US
Practice Address - Phone:904-270-0767
Practice Address - Fax:904-694-0058
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE79149Medicare UPIN
FL80446UMedicare ID - Type Unspecified