Provider Demographics
NPI:1891762258
Name:BUNDY, MARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY LYNN
Middle Name:
Last Name:BUNDY
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 1:1919 STATE ST
Mailing Address - Street 2:SUITE 362
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4929
Mailing Address - Country:US
Mailing Address - Phone:812-944-5888
Mailing Address - Fax:
Practice Address - Street 1:1108 NORTHVIEW DR STE 1
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133
Practice Address - Country:US
Practice Address - Phone:937-393-5781
Practice Address - Fax:937-393-5784
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037496A208000000X
KY26544208000000X
OH35.134104208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64265440Medicaid
IN200454960AMedicaid
OH0297624Medicaid
IN210400BMedicare PIN