Provider Demographics
NPI:1891891347
Name:MUNDEN, REGINALD F (MD, DMD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:F
Last Name:MUNDEN
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL286662085B0100X
NC2016-021252085R0202X
TXJ83282085R0202X
SC154862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009914017Medicaid
AL051546435OtherBCBS OF AL
AL009914018Medicaid
AL009914019Medicaid
AL051546439OtherBCBS OF AL
ALG04973OtherVIVA
AL009914016Medicaid
AL051546438OtherBCBS OF AL
AL051546440OtherBCBS OF AL
AL009914021Medicaid
AL051546437OtherBCBS OF AL
AL051546437OtherBCBS OF AL
G04973Medicare UPIN
AL510I300055Medicare PIN
82M954Medicare ID - Type Unspecified
AL009914017Medicaid