Basic Information
| Provider Information | |||||||||
| NPI: | 1447488762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNDY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2009 N MAIN ST | ||||||||
| Address2: | PREMIER PEDIATRICS | ||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188164024 | ||||||||
| FaxNumber: | 9188164025 | ||||||||
| Practice Location | |||||||||
| Address1: | 2009 N MAIN ST | ||||||||
| Address2: | PREMIER PEDIATRICS | ||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188164024 | ||||||||
| FaxNumber: | 9188164025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 27222 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.