Provider Demographics
NPI:1023111200
Name:MUKUNDAN, DEEPA (MD)
Entity type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:
Last Name:MUKUNDAN
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 1:4510 DORR ST # MS 840
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4040
Mailing Address - Country:US
Mailing Address - Phone:419-383-5334
Mailing Address - Fax:
Practice Address - Street 1:2150 W CENTRAL AVE FL 2
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3834
Practice Address - Country:US
Practice Address - Phone:419-291-5599
Practice Address - Fax:419-291-6468
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0881762080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2694731Medicaid