Provider Demographics
NPI:1477712321
Name:MAMIGONIAN, JACQUES (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:
Last Name:MAMIGONIAN
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8446
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:
Practice Address - Street 1:2612 W VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77807-4881
Practice Address - Country:US
Practice Address - Phone:979-207-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26421207Q00000X
TXN0943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine