Provider Demographics
NPI:1114816634
Name:MUNDACKAL, MARTIN ALEX (OD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:ALEX
Last Name:MUNDACKAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:THORNWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:10594-1204
Mailing Address - Country:US
Mailing Address - Phone:212-433-0136
Mailing Address - Fax:
Practice Address - Street 1:4204 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3706
Practice Address - Country:US
Practice Address - Phone:917-920-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011180152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist