Basic Information
| Provider Information | |||||||||
| NPI: | 1437183415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUNGARA | ||||||||
| FirstName: | ANIL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5727 ROSINWEED LN | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605641635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732137370 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 SW 160TH AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330276308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543994621 | ||||||||
| FaxNumber: | 8778929770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01069767A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208600000X | 01069767A | IN | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4888861 | 05 | MI | MEDICAID | 5315025419 | 01 | CONTROLLED SUBSTANCE | OTHER |