Provider Demographics
NPI:1669553731
Name:MUJUMDAR, SULABHA S (MD)
Entity type:Individual
Prefix:DR
First Name:SULABHA
Middle Name:S
Last Name:MUJUMDAR
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 1:3601 WEST CUMBERLAND AVENUE
Mailing Address - Street 2:P.O. BOX 1208
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965
Mailing Address - Country:US
Mailing Address - Phone:606-248-3100
Mailing Address - Fax:606-248-4141
Practice Address - Street 1:3601 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2613
Practice Address - Country:US
Practice Address - Phone:606-248-3100
Practice Address - Fax:606-248-4141
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19968174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0033734OtherBLUE CARE/TN CARE SELECT
VA006234241Medicaid
KY2196OtherCHA
KY64199680Medicaid
TN3195877OtherTN MEDICAID
KY000000047394OtherBLUE CROSS
KYK04395OtherCHAMPUS
KY1307695OtherUMWA
KY64199680Medicaid
KY1340401Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER