MEDICARE: DR. JEFFREY B MUNDORF M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	A50612	CA

General Provider Information

NPI Number	:	1598746174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY B MUNDORF M.D.

Provider Business Mailing Address
First Line	:	1551 BISHOP ST STE 230
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-4661
Country	:	US
Telephone Number	:	805-434-5530
Fax Number	:	805-434-0023

Provider Business Practice Location Address
First Line	:	1551 BISHOP ST STE 230
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-4661
Country	:	US
Telephone Number	:	805-434-5530
Fax Number	:	805-434-0023

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	10/02/2024

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