Provider Demographics
NPI:1467463588
Name:MUNDA, PETER (CH)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:MUNDA
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 GLEN ST
Mailing Address - Street 2:SUITE 380
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2858
Mailing Address - Country:US
Mailing Address - Phone:516-759-2424
Mailing Address - Fax:516-759-6627
Practice Address - Street 1:70 GLEN ST
Practice Address - Street 2:SUITE 380
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2858
Practice Address - Country:US
Practice Address - Phone:516-759-2424
Practice Address - Fax:516-759-6627
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0002739-1111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT52221Medicare UPIN
NYX16111Medicare ID - Type Unspecified