Healthcare Provider Details

I. General information

NPI: 1669543138
Provider Name (Legal Business Name): JOHN MUNDALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HILYARD ST STE S420
EUGENE OR
97401-8160
US

IV. Provider business mailing address

1200 HILYARD ST STE S420
EUGENE OR
97401-8160
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-2837
  • Fax: 541-687-0256
Mailing address:
  • Phone: 541-686-2837
  • Fax: 541-687-0256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD09779
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier231571
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: