Provider Demographics
NPI:1265523427
Name:MUNDAKEL, GRATIAS TOM (M D)
Entity type:Individual
Prefix:DR
First Name:GRATIAS
Middle Name:TOM
Last Name:MUNDAKEL
Suffix:
Gender:M
Credentials:M D
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Other - Credentials:
Mailing Address - Street 1:700 VICTORY BLVD
Mailing Address - Street 2:APT 5L
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301
Mailing Address - Country:US
Mailing Address - Phone:516-358-0186
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE, C4128
Practice Address - Street 2:KINGS COUNTY HOSPITAL CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:10301
Practice Address - Country:US
Practice Address - Phone:718-245-4753
Practice Address - Fax:718-245-2141
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0020682080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI51609Medicare UPIN