Individual
DR. LATA TAVANANDI MUNDKUR
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
817 MERRIMACK ST, SECOND FLOOR, LOWELL, MA 01854-3571
(978) 452-0672
Mailing address
817 MERRIMACK ST, SECOND FLOOR, LOWELL, MA 01854-3571
(978) 452-0672
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
58514
MA
207R00000X
Internal Medicine Physician
Primary
58514
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0017292
NEIGHBORHOOD HEALTH PLAN
MA
01
—
04-3117888
COVENTRY
MA
01
—
0401929
UNITED HEALTH CARE
MA
01
—
043117888
FEDERAL TAX ID
MA
01
—
0466975
AETNA US HEALTHCARE
MA
01
—
058514
TUFTS HEALTH PLAN
MA
01
—
109517
GREAT-WEST (ONE HEALTH)
MA
01
—
1487645248
CELTICARE
MA
01
—
22D0943104
CLIA
MA
01
—
2449768
CIGNA
MA
05
—
3015599
—
MA
01
—
33756
UNICARE - HEALTHY START
MA
01
—
4328196
AETNA
MA
01
—
45819
FALLON COMMUNITY
MA
01
—
65438
HARVARD PILGRIM
MA
01
—
970357
NETWORK HEALTH
MA
01
—
J06028
BLUE CROSS BLUE SHIELD
MA
Enumeration date
11/02/2005
Last updated
08/09/2011
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