Individual
DR. JACOB ADAM MONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
5680 W GAGE ST, BOISE, ID 83706-1326
(208) 377-3937
(208) 377-9455
Mailing address
5680 W GAGE ST, BOISE, ID 83706-1326
(208) 377-3937
(208) 377-9455
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
1346535481
MI
207W00000X
Ophthalmology Physician
Primary
O-0860
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1346535481
—
ID
01
—
20006959
MEDICARE PTAN
ID
Enumeration date
06/16/2011
Last updated
05/08/2023
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