Provider Demographics
NPI:1205947959
Name:BODENDORFER, KARL D (MD)
Entity type:Individual
Prefix:DR
First Name:KARL
Middle Name:D
Last Name:BODENDORFER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:KARL
Other - Middle Name:DAVID
Other - Last Name:BODENDORFER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-0489
Mailing Address - Country:US
Mailing Address - Phone:386-755-2785
Mailing Address - Fax:386-755-2785
Practice Address - Street 1:1615 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1108
Practice Address - Country:US
Practice Address - Phone:386-755-2785
Practice Address - Fax:386-755-1128
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78478207R00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001933700Medicaid
FL259120101Medicaid
FLP00087109OtherRAILROAD MEDICARE
FL35612AOtherBC/BS
FL259120100Medicaid
H02084Medicare UPIN
FL259120100Medicaid
FL35612YMedicare PIN