Provider Demographics
NPI:1457448821
Name:MUNGOVAN, MICHAEL THOMAS (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:MUNGOVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 ILLINOIS RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5114
Mailing Address - Country:US
Mailing Address - Phone:260-447-1067
Mailing Address - Fax:260-447-0827
Practice Address - Street 1:4705 ILLINOIS RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5108
Practice Address - Country:US
Practice Address - Phone:260-447-1067
Practice Address - Fax:260-447-0827
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001044111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN226000AOtherMEDICARE PTAN
INP00311763OtherRR MEDICARE
KY000000343299OtherANTHEM BCBS