Healthcare Provider Details

I. General information

NPI: 1205882214
Provider Name (Legal Business Name): JOHN D MUNDY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 SAN PABLO RD S STE 20
JACKSONVILLE FL
32224
US

IV. Provider business mailing address

4500 SAN PABLO RD S STE 20
JACKSONVILLE FL
32224-1865
US

V. Phone/Fax

Practice location:
  • Phone: 909-495-3200
  • Fax: 763-450-3986
Mailing address:
  • Phone: 909-495-3200
  • Fax: 763-450-3986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11001687
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR146429-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: