Provider Demographics
NPI:1629389184
Name:MENGANG, JOELLE M (MD)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:M
Last Name:MENGANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOELLE
Other - Middle Name:M
Other - Last Name:METUGE MESINZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-336-3125
Practice Address - Street 1:2750 11TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5216
Practice Address - Country:US
Practice Address - Phone:563-336-3000
Practice Address - Fax:563-327-2102
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39066207Q00000X
IA40773207Q00000X
NC2015-02157207Q00000X
IL036134016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2691Medicaid
IA1932193224Medicaid
NC1629389184Medicaid
NC1629389184Medicaid
NCNCS389AMedicare PIN