Individual
JONATHAN M MONGOLD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
5177 MCCARTY LN, LAFAYETTE, IN 47905-8764
(765) 448-8000
Mailing address
1200 W WHITE RIVER BLVD # 4300, MUNCIE, IN 47303-4988
(877) 668-5621
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
02005180A
IN
207Q00000X
Family Medicine Physician
Primary
02005180A
IN
207QS0010X
Sports Medicine (Family Medicine) Physician
02005180A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001106441
ANTHEM SPORTS MED PIN
IN
01
—
000001116759
ANTHEM FAMILY MED PIN
IN
01
—
000001117320
ANTHEM URGENT CARE PIN
IN
05
—
300005550
—
IN
Enumeration date
04/04/2013
Last updated
01/27/2021
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