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General NPI Number Information
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NPI Number | 1245459775
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Entity Type | Organization
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Legal Business Name | GARY MUNDY MD LLC
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1955 COFFEEN AVE
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City | SHERIDAN
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State | WY
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Zip | 82801-5713
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Country | US
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Telephone | 307-673-7560
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Fax |
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Provider Business Mailing Address
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Address Line | 1955 COFFEEN AVE
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City | SHERIDAN
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State | WY
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Zip | 82801-5713
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Country | US
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Telephone | 307-673-7560
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GARY D MUNDY
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Credential | MD
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Telephone | 307-673-7560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5258A
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License Number State | WY
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