Provider Demographics
NPI:1356463939
Name:MUNGARA, PADMANABHA RAJU (MD)
Entity type:Individual
Prefix:DR
First Name:PADMANABHA RAJU
Middle Name:
Last Name:MUNGARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3601
Mailing Address - Country:US
Mailing Address - Phone:727-582-7712
Mailing Address - Fax:
Practice Address - Street 1:647 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3601
Practice Address - Country:US
Practice Address - Phone:727-582-7712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN218207Q00000X
GA056853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine