Provider Demographics
NPI:1285043505
Name:MICHAEL A MUNDELL, MD, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL A MUNDELL, MD, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:MUNDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-291-3193
Mailing Address - Street 1:1400 QUAIL CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-2043
Mailing Address - Country:US
Mailing Address - Phone:707-538-5528
Mailing Address - Fax:
Practice Address - Street 1:1400 QUAIL CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-2043
Practice Address - Country:US
Practice Address - Phone:707-538-5528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28146207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty