1265523427 NPI number — DR. GRATIAS TOM MUNDAKEL M. D.

Table of content: DR. GRATIAS TOM MUNDAKEL M. D. (NPI 1265523427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265523427 NPI number — DR. GRATIAS TOM MUNDAKEL M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNDAKEL
Provider First Name:
GRATIAS
Provider Middle Name:
TOM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M. D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265523427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 VICTORY BLVD
Provider Second Line Business Mailing Address:
APT 5L
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-358-0186
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 CLARKSON AVE, C4128
Provider Second Line Business Practice Location Address:
KINGS COUNTY HOSPITAL CENTER
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-245-4753
Provider Business Practice Location Address Fax Number:
718-245-2141
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080N0001X , with the licence number:  002068 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 119634700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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