Provider Demographics
NPI:1003514365
Name:MUNDAM, CROMWELL
Entity Type:Individual
Prefix:
First Name:CROMWELL
Middle Name:
Last Name:MUNDAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10037 LOCUST ST GLENDALE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769
Mailing Address - Country:US
Mailing Address - Phone:240-970-0903
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3011
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:202-894-6811
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator