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General NPI Number Information
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NPI Number | 1114816634
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Entity Type | Individual
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Provider Name | MARTIN ALEX MUNDACKAL OD
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Gender | Male
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Dates
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Enumeration Date | 06/30/2025
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Last Update Date | 07/07/2025
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Provider Practice Location Address
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Address Line | 4204 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10033-3706
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Country | US
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Telephone | 917-920-2636
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Fax |
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Provider Business Mailing Address
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Address Line | 212 BENEDICT AVE
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City | THORNWOOD
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State | NY
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Zip | 10594-1204
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Country | US
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Telephone | 212-433-0136
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 011180
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License Number State | NY
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