1487645248 NPI number — DR. LATA TAVANANDI MUNDKUR M.D.

Table of content: DR. LATA TAVANANDI MUNDKUR M.D. (NPI 1487645248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487645248 NPI number — DR. LATA TAVANANDI MUNDKUR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNDKUR
Provider First Name:
LATA
Provider Middle Name:
TAVANANDI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1487645248
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 MERRIMACK ST
Provider Second Line Business Mailing Address:
SECOND FLOOR
Provider Business Mailing Address City Name:
LOWELL
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01854-3571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-452-0672
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 MERRIMACK ST
Provider Second Line Business Practice Location Address:
SECOND FLOOR
Provider Business Practice Location Address City Name:
LOWELL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01854-3571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-452-0672
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2005

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: 207Q00000X , with the licence number:  58514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 58514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0466975 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1487645248 . This is a "CELTICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4328196 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 970357 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J06028 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017292 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043117888 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 058514 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 04-3117888 . This is a "COVENTRY" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 04-3117888 . This is a "GREAT-WEST" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 04-3117888 . This is a "MULTIPLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3015599 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0401929 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043117888 . This is a "TRICARE-NORTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 22D0943104 . This is a "CLIA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2449768 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 04-3117888 . This is a "BEECH STREET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 109517 . This is a "GREAT-WEST (ONE HEALTH)" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 33756 . This is a "UNICARE - HEALTHY START" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 45819 . This is a "FALLON COMMUNITY" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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