Provider Demographics
NPI:1639115298
Name:MONGUILOD, JUAN-CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN-CARLOS
Middle Name:
Last Name:MONGUILOD
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 1:2500 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4522
Mailing Address - Country:US
Mailing Address - Phone:336-621-2500
Mailing Address - Fax:336-478-2541
Practice Address - Street 1:2500 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4522
Practice Address - Country:US
Practice Address - Phone:336-621-2500
Practice Address - Fax:336-478-2541
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1174FOtherBCBS
NC891174FMedicaid
NC188390OtherMEDCOST
NC2670503OtherUHC
NCG77439Medicare UPIN
NC2258245BMedicare ID - Type UnspecifiedPART B