Provider Demographics
NPI:1447488762
Name:MUNDY, RYAN T (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:T
Last Name:MUNDY
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 1:2009 N MAIN ST
Mailing Address - Street 2:PREMIER PEDIATRICS
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4131
Mailing Address - Country:US
Mailing Address - Phone:918-816-4024
Mailing Address - Fax:918-816-4025
Practice Address - Street 1:2009 N MAIN ST
Practice Address - Street 2:PREMIER PEDIATRICS
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4131
Practice Address - Country:US
Practice Address - Phone:918-816-4024
Practice Address - Fax:918-816-4025
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27222208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics