Provider Demographics
NPI:1093794943
Name:MUNDODI, BALAKRISHNA (MD)
Entity Type:Individual
Prefix:DR
First Name:BALAKRISHNA
Middle Name:
Last Name:MUNDODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 E RUSHOLME ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2473
Mailing Address - Country:US
Mailing Address - Phone:563-324-2992
Mailing Address - Fax:563-324-8562
Practice Address - Street 1:350 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6899
Practice Address - Country:US
Practice Address - Phone:309-743-6700
Practice Address - Fax:309-764-2042
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
060051143OtherMEDICARE RAILROAD
IL036066456Medicaid
IA1955849Medicaid
ILL64220Medicare PIN
IA44561Medicare PIN
060051143OtherMEDICARE RAILROAD