Provider Demographics
NPI:1528093176
Name:MUNJACK, ELLIOT L (MD)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:L
Last Name:MUNJACK
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 1:18228 GRESHAM ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-3023
Mailing Address - Country:US
Mailing Address - Phone:818-886-0932
Mailing Address - Fax:
Practice Address - Street 1:18228 GRESHAM ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-3023
Practice Address - Country:US
Practice Address - Phone:818-886-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41579207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48618Medicare UPIN