Basic Information
| Provider Information | |||||||||
| NPI: | 1972689883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNGO | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 340 | ||||||||
| Address2: | |||||||||
| City: | HALIFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345751683 | ||||||||
| FaxNumber: | 4345751682 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 WILBORN AVENUE | ||||||||
| Address2: | HALIFAX REGIONAL HOSPITAL | ||||||||
| City: | HALIFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345173187 | ||||||||
| FaxNumber: | 4345173686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085R0202X | 0101235169 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 002596 | 01 | BC | OTHER |