Provider Demographics
NPI:1154385383
Name:MUNDORFF, THOMAS NELSON (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:NELSON
Last Name:MUNDORFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 OLIVE HWY
Mailing Address - Street 2:STE 12
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966
Mailing Address - Country:US
Mailing Address - Phone:530-533-6061
Mailing Address - Fax:530-533-4438
Practice Address - Street 1:2721 OLIVE HWY
Practice Address - Street 2:STE 12
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966
Practice Address - Country:US
Practice Address - Phone:530-533-6061
Practice Address - Fax:530-533-4438
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG25438OtherSTATE LICENSE
CAGR0014101Medicaid
CAGR0014101Medicaid
CAGR0014101Medicaid
A42668Medicare UPIN