Provider Demographics
NPI:1730191610
Name:MUKUNDAN, SHANMUGAM (MD)
Entity type:Individual
Prefix:
First Name:SHANMUGAM
Middle Name:
Last Name:MUKUNDAN
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 1:10401 W THUNDERBIRD BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3004
Mailing Address - Country:US
Mailing Address - Phone:623-876-5622
Mailing Address - Fax:623-815-2931
Practice Address - Street 1:10401 W THUNDERBIRD BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3004
Practice Address - Country:US
Practice Address - Phone:623-876-5622
Practice Address - Fax:623-815-2931
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229163207R00000X
AZ37254207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
690545OtherNCPPO
G0157201OtherRAILROAD MEDICARE
K012OtherBLUECROSS CAREFIRST NCA
AETNAOther201020956
VA010151431Medicaid
201020956OtherCIGNA
2128136OtherALLIANCE
8128136OtherOPTIMUM CHOICE
13965OtherANTHEM
8128136OtherUNITED HEALTH CARE
13965OtherANTHEM
VA010151431Medicaid
AZZ124180Medicare PIN