Basic Information
| Provider Information | |||||||||
| NPI: | 1730191610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUKUNDAN | ||||||||
| FirstName: | SHANMUGAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10401 W THUNDERBIRD BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238765622 | ||||||||
| FaxNumber: | 6238152931 | ||||||||
| Practice Location | |||||||||
| Address1: | 10401 W THUNDERBIRD BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238765622 | ||||||||
| FaxNumber: | 6238152931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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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 | 207R00000X | 0101229163 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 37254 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 690545 | 01 | NCPPO | OTHER | G0157201 | 01 | RAILROAD MEDICARE | OTHER | K012 | 01 | BLUECROSS CAREFIRST NCA | OTHER | AETNA | 01 | 201020956 | OTHER | 010151431 | 05 | VA | MEDICAID | 201020956 | 01 | CIGNA | OTHER | 2128136 | 01 | ALLIANCE | OTHER | 8128136 | 01 | OPTIMUM CHOICE | OTHER | 13965 | 01 | ANTHEM | OTHER | 8128136 | 01 | UNITED HEALTH CARE | OTHER |