Provider Demographics
NPI:1912185588
Name:MUNDALL, JON MARCUS RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:JON MARCUS
Middle Name:RAYMOND
Last Name:MUNDALL
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:PO BOX F
Mailing Address - Street 2:
Mailing Address - City:CONNELL
Mailing Address - State:WA
Mailing Address - Zip Code:99326-0047
Mailing Address - Country:US
Mailing Address - Phone:509-234-7766
Mailing Address - Fax:509-234-4320
Practice Address - Street 1:111 NORTH COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326
Practice Address - Country:US
Practice Address - Phone:509-234-7766
Practice Address - Fax:509-234-4320
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023408208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A15157Medicare UPIN