Provider Demographics
NPI:1508056227
Name:MONDEREWICZ, KATHLEEN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:MONDEREWICZ
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 1:119 BELLEFONTE DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2109
Mailing Address - Country:US
Mailing Address - Phone:606-325-6967
Mailing Address - Fax:304-525-4231
Practice Address - Street 1:612 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2104
Practice Address - Country:US
Practice Address - Phone:304-525-4202
Practice Address - Fax:304-525-4231
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36297207Q00000X
WV21708207Q00000X
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine