Provider Demographics
NPI:1043898992
Name:MUNDACKAL, NICOLE ROSE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:MUNDACKAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 LEO LN
Mailing Address - Street 2:
Mailing Address - City:POUGHQUAG
Mailing Address - State:NY
Mailing Address - Zip Code:12570-5402
Mailing Address - Country:US
Mailing Address - Phone:845-514-5982
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2020
Practice Address - Fax:631-444-2894
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program