Provider Demographics
NPI:1558369652
Name:MUND, DOUGLAS JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAY
Last Name:MUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1575 HILLSIDE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2501
Mailing Address - Country:US
Mailing Address - Phone:516-354-3400
Mailing Address - Fax:516-354-0553
Practice Address - Street 1:2800 MARCUS AVENUE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-622-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128108207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB14969Medicare UPIN
NY47A621Medicare PIN