Basic Information
| Provider Information | |||||||||
| NPI: | 1124006192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONDOA | ||||||||
| FirstName: | EMIL | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 HADDON AVE | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081033101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567573988 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 HADDON AVE | ||||||||
| Address2: | ICN | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081033101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567573988 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA05423800 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8227004 | 05 | NJ | MEDICAID |