Provider Demographics
NPI:1235469503
Name:MUNDRA, VISHAL (MBBS)
Entity Type:Individual
Prefix:DR
First Name:VISHAL
Middle Name:
Last Name:MUNDRA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N HARVARD AVE
Mailing Address - Street 2:STE E
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-4957
Mailing Address - Country:US
Mailing Address - Phone:918-832-6049
Mailing Address - Fax:918-832-6055
Practice Address - Street 1:1705 E 19TH ST
Practice Address - Street 2:STE 302
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5405
Practice Address - Country:US
Practice Address - Phone:918-748-7599
Practice Address - Fax:918-748-7539
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN12648207R00000X
OK28366207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK28366OtherOK ST LICENSE