1629029012 NPI number — MR. CHARLES R MUND OD.

Table of content: MR. CHARLES R MUND OD. (NPI 1629029012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629029012 NPI number — MR. CHARLES R MUND OD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUND
Provider First Name:
CHARLES
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OD.
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:
1629029012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5701 GREENBELT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERWYN HEIGHTS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20740-2257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-345-2053
Provider Business Mailing Address Fax Number:
301-441-1752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 GREENBELT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERWYN HEIGHTS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20740-2257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-345-2053
Provider Business Practice Location Address Fax Number:
301-441-1752
Provider Enumeration Date:
05/12/2006

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: 152W00000X , with the licence number:  TAO866 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WV0400X , with the licence number: TAO866 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 091730300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1003325 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 271019 . This is a "MAMSI/ALLIANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 89160003 . This is a "BC/BS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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