Provider Demographics
NPI:1598746174
Name:MUNDORF, JEFFREY B (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
Last Name:MUNDORF
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 1:1551 BISHOP ST STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4661
Mailing Address - Country:US
Mailing Address - Phone:805-434-5530
Mailing Address - Fax:805-434-0023
Practice Address - Street 1:1304 ELLA ST STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4165
Practice Address - Country:US
Practice Address - Phone:805-549-9555
Practice Address - Fax:805-549-0444
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50612207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF50634Medicare UPIN
CAWA50612JMedicare PIN
CAA50612Medicare ID - Type Unspecified