Provider Demographics
NPI:1104883164
Name:MUNDERLOH, TIMOTHY JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:MUNDERLOH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E CEDAR AVE
Mailing Address - Street 2:STE 80
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-556-0707
Mailing Address - Fax:928-522-8462
Practice Address - Street 1:1500 E CEDAR AVE
Practice Address - Street 2:STE 80
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-556-0707
Practice Address - Fax:928-522-8462
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5935111N00000X
AZ1058111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0941160OtherBCBS
624131OtherUNITED HEALTH CARE
AZAZ0941160OtherBCBS
U81754Medicare UPIN