Provider Demographics
NPI:1649423872
Name:MUNGARA, CHARAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARAN
Middle Name:
Last Name:MUNGARA
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 1:353 FAIRMONT BLVD, MONUMENT HEALTH RAPID CITY HOSPITAL
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7375
Mailing Address - Country:US
Mailing Address - Phone:205-441-9459
Mailing Address - Fax:605-755-0707
Practice Address - Street 1:353 FAIRMONT BLVD, MONUMENT HEALTH RAPID CITY HOSPITAL
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:205-441-9459
Practice Address - Fax:605-755-0707
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11971208G00000X
IN01069999A208G00000X
WI53213-020208600000X
WI53213208G00000X
TN50234208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201029750Medicaid
IN000000727503OtherANTHEM PROVIDER NUMBER
WI1649423872Medicaid
INM400053465Medicare PIN
WI1649423872Medicaid
INM400058019Medicare PIN
IN201029750Medicaid