1972605434 NPI number — DR. FABRIZIO MONGE M.D.

Table of content: DR. FABRIZIO MONGE M.D. (NPI 1972605434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972605434 NPI number — DR. FABRIZIO MONGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONGE
Provider First Name:
FABRIZIO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972605434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4235 KINGS HWY
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33980-8421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-613-1777
Provider Business Mailing Address Fax Number:
941-613-1779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25086 OLYMPIA AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PUNTA GORDA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33950-3933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-205-5300
Provider Business Practice Location Address Fax Number:
941-205-5302
Provider Enumeration Date:
09/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  ME100488 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 35131 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000330600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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