Provider Demographics
NPI:1215010863
Name:MONGOLD, BRADLEY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WAYNE
Last Name:MONGOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1150
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-1150
Mailing Address - Country:US
Mailing Address - Phone:304-264-1000
Mailing Address - Fax:304-254-1374
Practice Address - Street 1:2500 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-264-1000
Practice Address - Fax:304-254-1374
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV21986207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I44194Medicare UPIN