Healthcare Provider Details

I. General information

NPI: 1477762037
Provider Name (Legal Business Name): JOEL R MUNDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/29/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11060 ANDERSON ST
LOMA LINDA CA
92350-2751
US

IV. Provider business mailing address

PO BOX F
CONNELL WA
99326-0047
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-5610
  • Fax: 909-558-0242
Mailing address:
  • Phone: 509-234-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA101059
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA101059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: