Provider Demographics
NPI:1669695425
Name:WUNDERLER, DENISE LYNN (DO)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:LYNN
Last Name:WUNDERLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 US 9 STE B
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-8304
Mailing Address - Country:US
Mailing Address - Phone:732-683-1800
Mailing Address - Fax:
Practice Address - Street 1:4251 US 9 STE B
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-8304
Practice Address - Country:US
Practice Address - Phone:732-683-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10009200207QS0010X
MO2009032595207Q00000X, 207QS0010X
OH34.008956207Q00000X, 207QS0010X
KY03407207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00817789OtherRAILROAD MEDICARE-SJC
MO1669695425Medicaid
MO431560263OtherTRICARE WEST
MO132300094Medicare PIN
P00817789OtherRAILROAD MEDICARE-SJC