Provider Demographics
NPI:1003039348
Name:JOB B MONGARE, MD
Entity Type:Organization
Organization Name:JOB B MONGARE, MD
Other - Org Name:ATHENS NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOB
Authorized Official - Middle Name:B
Authorized Official - Last Name:MONGARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-677-5006
Mailing Address - Street 1:115 MEDICAL CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-9003
Mailing Address - Country:US
Mailing Address - Phone:903-677-5006
Mailing Address - Fax:903-677-9006
Practice Address - Street 1:115 MEDICAL CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-9003
Practice Address - Country:US
Practice Address - Phone:903-677-5006
Practice Address - Fax:903-677-9006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8954174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179550201Medicaid
TX00W327Medicare ID - Type Unspecified
TX179550201Medicaid