Provider Demographics
NPI:1225026180
Name:MUNDY, BRIAN JO (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JO
Last Name:MUNDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3443 VILLA LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6417
Mailing Address - Country:US
Mailing Address - Phone:707-253-8280
Mailing Address - Fax:707-253-7023
Practice Address - Street 1:3443 VILLA LN
Practice Address - Street 2:SUITE 2
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6417
Practice Address - Country:US
Practice Address - Phone:707-253-8280
Practice Address - Fax:707-253-7023
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA91150207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI37166Medicare UPIN