Provider Demographics
NPI:1558442855
Name:MONDORF, PAMELA (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MONDORF
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 492680
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-2680
Mailing Address - Country:US
Mailing Address - Phone:530-243-0440
Mailing Address - Fax:530-243-0445
Practice Address - Street 1:1320 BISHOP RANDALL DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3939
Practice Address - Country:US
Practice Address - Phone:307-332-4420
Practice Address - Fax:530-243-0445
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7004A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY10225Medicare ID - Type UnspecifiedMEDICARE ID #