Provider Demographics
NPI:1205179553
Name:MONGOLD, JONATHAN M (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:MONGOLD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD # 4300
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:5177 MCCARTY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8764
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005180A207P00000X, 207QS0010X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005550Medicaid
IN000001116759OtherANTHEM FAMILY MED PIN
IN000001106441OtherANTHEM SPORTS MED PIN
IN000001117320OtherANTHEM URGENT CARE PIN