Provider Demographics
NPI:1326782111
Name:MONGUE, RAUL ANTONIO SR
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:ANTONIO
Last Name:MONGUE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19797 NW 226TH TER
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-0664
Mailing Address - Country:US
Mailing Address - Phone:352-215-9460
Mailing Address - Fax:
Practice Address - Street 1:19797 NW 226TH TER
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-0664
Practice Address - Country:US
Practice Address - Phone:352-215-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM522-720-84-006-0172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver