Provider Demographics
NPI:1760670913
Name:MUNGEE, MEGHA
Entity Type:Individual
Prefix:
First Name:MEGHA
Middle Name:
Last Name:MUNGEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4675
Mailing Address - Country:US
Mailing Address - Phone:309-683-5700
Mailing Address - Fax:309-683-5752
Practice Address - Street 1:5111 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4675
Practice Address - Country:US
Practice Address - Phone:309-683-5700
Practice Address - Fax:309-683-5752
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2008-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
809840OtherMEDICARE GROUP #
K48668Medicare PIN