Provider Demographics
NPI:1437183415
Name:MUNGARA, ANIL K (MD)
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:K
Last Name:MUNGARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5727 ROSINWEED LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-1635
Mailing Address - Country:US
Mailing Address - Phone:773-213-7370
Mailing Address - Fax:
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:954-399-4621
Practice Address - Fax:877-892-9770
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069767A207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4888861Medicaid
5315025419OtherCONTROLLED SUBSTANCE