Provider Demographics
NPI:1275523557
Name:NGWANA-MONDOA, THERESA E (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:NGWANA-MONDOA
Suffix:
Gender:F
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 100445
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0445
Mailing Address - Country:US
Mailing Address - Phone:888-627-4702
Mailing Address - Fax:804-253-0408
Practice Address - Street 1:9901 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3357
Practice Address - Country:US
Practice Address - Phone:301-279-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057882208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3840018Medicaid
WV3810012438Medicaid