Basic Information
| Provider Information | |||||||||
| NPI: | 1992771075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUNDRA | ||||||||
| FirstName: | RAMESH | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | WOT 12TH FLOOR, ATTN: PHYSICIAN SERVICES | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685529 | ||||||||
| FaxNumber: | 5083685530 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 EAST MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WESTBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088982338 | ||||||||
| FaxNumber: | 5083669938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 38048 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | AA1254 | 01 | HARVARD PILGRIM | OTHER | E18009 | 01 | BLUE SHIELD INDEMNITY | OTHER | E18009 | 01 | MEDICARE B | OTHER | 2033658 | 05 | MA | MEDICAID | 5296161 | 01 | AETNA US HEALTHCARE | OTHER | 918070 | 01 | FIRST HEALTH | OTHER | E18009 | 01 | BLUE CARE ELECT | OTHER | 5327618 | 01 | CIGNA HEALTH PLAN | OTHER | 784164 | 01 | MVP HEALTH CARE | OTHER | 9900229 | 01 | FALLON COMMUNITY HEALTH | OTHER | 26841 | 01 | CHILDRENS MED SECURITY | OTHER | 2033658 | 01 | MEDICAID WELFARE | OTHER | E18009 | 01 | BLUE SHIELD HMO BLUE | OTHER |