Provider Demographics
NPI:1326023516
Name:MUND, DEBRA F (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:F
Last Name:MUND
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:DEPT LA 21559
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1559
Mailing Address - Country:US
Mailing Address - Phone:888-727-1073
Mailing Address - Fax:866-752-2240
Practice Address - Street 1:2202 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5706
Practice Address - Country:US
Practice Address - Phone:310-264-9000
Practice Address - Fax:310-264-9004
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG703902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G703900Medicaid
CA00G703900OtherBLUE SHIELD OF CA
CAWG70390MMedicare PIN
CAWG70390IMedicare PIN
CAWG70390KMedicare PIN
CA00G703900Medicaid
CAWG70390LMedicare PIN
G43912Medicare UPIN