Healthcare Provider Details

I. General information

NPI: 1609113513
Provider Name (Legal Business Name): TICHAENDEPI MUNDANGEPFUPFU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 06/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE # 604
ROCHESTER NY
14642-5504
US

IV. Provider business mailing address

601 ELMWOOD AVENUE BOX 604
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-1385
  • Fax:
Mailing address:
  • Phone: 585-275-1385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number301576
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number301576
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: