Basic Information
| Provider Information | |||||||||
| NPI: | 1598746174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNDORF | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 E MAIN ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934544890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1551 BISHOP ST | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054345530 | ||||||||
| FaxNumber: | 8057464220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | A50612 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.