Provider Demographics
NPI:1477940997
Name:PREMKUMAR, MUKUND (MD)
Entity Type:Individual
Prefix:
First Name:MUKUND
Middle Name:
Last Name:PREMKUMAR
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 1:1569 SLOAT BLVD STE 333
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1255
Mailing Address - Country:US
Mailing Address - Phone:415-353-9339
Mailing Address - Fax:
Practice Address - Street 1:1569 SLOAT BLVD STE 333
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1255
Practice Address - Country:US
Practice Address - Phone:415-353-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA162649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine