1376725929 NPI number — LARRY J MUNDY MD PA

Table of content: (NPI 1376725929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376725929 NPI number — LARRY J MUNDY MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY J MUNDY MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1376725929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20995
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WACO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76702-0995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-202-8675
Provider Business Mailing Address Fax Number:
254-202-6669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 HERRING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76708-3239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-202-8675
Provider Business Practice Location Address Fax Number:
254-202-6669
Provider Enumeration Date:
12/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MUNDY
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
254-202-8675

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  H1304 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0085MT . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com