Basic Information
| Provider Information | |||||||||
| NPI: | 1245266857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAJMUNDAR | ||||||||
| FirstName: | MAMATA | ||||||||
| MiddleName: | GOPAL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3099 HELMSDALE PL | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405092213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592586401 | ||||||||
| FaxNumber: | 8592551480 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 VERSAILLES RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592592635 | ||||||||
| FaxNumber: | 8592547874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 01/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37758 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 37903705 | 01 | KY | MEDICAID LAB GROUP# | OTHER | 4000501 | 01 | KY | MEDICARE LAB GROUP# | OTHER | 64066699 | 05 | KY | MEDICAID | P00034949 | 01 | GA | RR MEDICARE PIN# | OTHER | CB5773 | 01 | GA | RR MEDICARE GROUP# | OTHER |