Provider Demographics
NPI:1487645248
Name:MUNDKUR, LATA TAVANANDI (MD)
Entity Type:Individual
Prefix:DR
First Name:LATA
Middle Name:TAVANANDI
Last Name:MUNDKUR
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 1:817 MERRIMACK ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-3571
Mailing Address - Country:US
Mailing Address - Phone:978-452-0672
Mailing Address - Fax:
Practice Address - Street 1:817 MERRIMACK ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-3571
Practice Address - Country:US
Practice Address - Phone:978-452-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58514207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0466975OtherAETNA US HEALTHCARE
MA1487645248OtherCELTICARE
MA4328196OtherAETNA
MA970357OtherNETWORK HEALTH
MAJ06028OtherBLUE CROSS BLUE SHIELD
MA0017292OtherNEIGHBORHOOD HEALTH PLAN
MA043117888OtherFEDERAL TAX ID
MA058514OtherTUFTS HEALTH PLAN
MA04-3117888OtherCOVENTRY
MA04-3117888OtherGREAT-WEST
MA04-3117888OtherMULTIPLAN
MA3015599Medicaid
MA0401929OtherUNITED HEALTH CARE
MA043117888OtherTRICARE-NORTH
MA22D0943104OtherCLIA
MA2449768OtherCIGNA
MA04-3117888OtherBEECH STREET
MA109517OtherGREAT-WEST (ONE HEALTH)
MA33756OtherUNICARE - HEALTHY START
MA45819OtherFALLON COMMUNITY
MA65438OtherHARVARD PILGRIM
MA3015599Medicaid
MA970357OtherNETWORK HEALTH
MA04-3117888OtherMULTIPLAN