Provider Demographics
NPI:1558324228
Name:MONGILLO, ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:MONGILLO
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 1:3180 MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4237
Mailing Address - Country:US
Mailing Address - Phone:203-373-9100
Mailing Address - Fax:203-365-8492
Practice Address - Street 1:3180 MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4237
Practice Address - Country:US
Practice Address - Phone:203-373-9100
Practice Address - Fax:203-365-8492
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023825207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001238252Medicaid
CT001238252Medicaid
CT110006327Medicare ID - Type Unspecified