Provider Demographics
NPI:1053420364
Name:MUNDY, BRIAN LEWIS (PT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LEWIS
Last Name:MUNDY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S 11TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5767
Mailing Address - Country:US
Mailing Address - Phone:352-787-3609
Mailing Address - Fax:352-314-8979
Practice Address - Street 1:26540 ACE AVE
Practice Address - Street 2:STE B
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8279
Practice Address - Country:US
Practice Address - Phone:352-314-9810
Practice Address - Fax:352-314-9878
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY910DOtherBCBS