Healthcare Provider Details

I. General information

NPI: 1245626365
Provider Name (Legal Business Name): KATHLEEN MUNGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX MED
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 278984
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-2222
  • Fax:
Mailing address:
  • Phone: 585-275-7854
  • Fax: 585-275-9953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number296353
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: