Provider Demographics
NPI:1427525633
Name:MUNDT, ERIC THOMAS
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:THOMAS
Last Name:MUNDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 PEMBERTON ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14622
Mailing Address - Country:US
Mailing Address - Phone:585-317-0683
Mailing Address - Fax:
Practice Address - Street 1:393 PEMBERTON ROAD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622
Practice Address - Country:US
Practice Address - Phone:585-317-0683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY25435390200000X
NY025435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program