Provider Demographics
NPI:1245266857
Name:MAJMUNDAR, MAMATA GOPAL (MD)
Entity type:Individual
Prefix:
First Name:MAMATA
Middle Name:GOPAL
Last Name:MAJMUNDAR
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 1:3099 HELMSDALE PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2213
Mailing Address - Country:US
Mailing Address - Phone:859-258-6401
Mailing Address - Fax:859-255-1480
Practice Address - Street 1:1306 VERSAILLES RD STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1795
Practice Address - Country:US
Practice Address - Phone:859-259-2635
Practice Address - Fax:859-254-7874
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2018-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37903705OtherMEDICAID LAB GROUP#
KY4000501OtherMEDICARE LAB GROUP#
KY64066699Medicaid
GAP00034949OtherRR MEDICARE PIN#
GACB5773OtherRR MEDICARE GROUP#
GAP00034949OtherRR MEDICARE PIN#
KY0623732Medicare ID - Type Unspecified
H77621Medicare UPIN
KY4000501OtherMEDICARE LAB GROUP#