Provider Demographics
NPI:1295759868
Name:URMUNDALAVAUR, MALLIKARJUNA B (MD)
Entity type:Individual
Prefix:MR
First Name:MALLIKARJUNA
Middle Name:B
Last Name:URMUNDALAVAUR
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 1:4415 US HIGHWAY 331 S STE A
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-6307
Mailing Address - Country:US
Mailing Address - Phone:850-682-5332
Mailing Address - Fax:850-682-8486
Practice Address - Street 1:4415 US HIGHWAY 331 S STE A
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-6307
Practice Address - Country:US
Practice Address - Phone:850-682-5332
Practice Address - Fax:850-682-8486
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75135174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34078OtherBLUE CROSS BLUE SHIELD