Provider Demographics
NPI:1215213160
Name:MYNE, PUJA K (MD)
Entity Type:Individual
Prefix:
First Name:PUJA
Middle Name:K
Last Name:MYNE
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 1:300 20TH AVE N STE 403
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-5180
Mailing Address - Country:US
Mailing Address - Phone:615-284-7261
Mailing Address - Fax:
Practice Address - Street 1:2723 NEW SALEM HWY
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-5253
Practice Address - Country:US
Practice Address - Phone:615-396-6850
Practice Address - Fax:615-396-6855
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN53109207Q00000X
WI56462-20390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215213160Medicaid
WI541760867Medicare PIN
IL$$$$$$$$$ 1Medicaid
WIMYNEPUJOtherMERCYCARE INSURANCE