Healthcare Provider Details

I. General information

NPI: 1265523427
Provider Name (Legal Business Name): GRATIAS TOM MUNDAKEL M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE, C4128 KINGS COUNTY HOSPITAL CENTER
BROOKLYN NY
10301
US

IV. Provider business mailing address

700 VICTORY BLVD APT 5L
STATEN ISLAND NY
10301
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-4753
  • Fax: 718-245-2141
Mailing address:
  • Phone: 516-358-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number002068
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: