Provider Demographics
NPI:1730156811
Name:GUNDANNA, MUKUND I (MD)
Entity type:Individual
Prefix:
First Name:MUKUND
Middle Name:I
Last Name:GUNDANNA
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 1:3526 LONGMIRE DR
Mailing Address - Street 2:STE 101
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6473
Mailing Address - Country:US
Mailing Address - Phone:979-693-1815
Mailing Address - Fax:979-693-4706
Practice Address - Street 1:1602 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 2400
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8306
Practice Address - Country:US
Practice Address - Phone:979-693-1815
Practice Address - Fax:979-693-4706
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8709207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166886501Medicaid
TX8C0031Medicare ID - Type Unspecified
TX166886501Medicaid