Provider Demographics
NPI:1639148703
Name:MON, MICHELLE DIANA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANA
Last Name:MON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DIANA
Other - Last Name:ELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3407 WILKENS AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5074
Mailing Address - Country:US
Mailing Address - Phone:443-574-8500
Mailing Address - Fax:
Practice Address - Street 1:3407 WILKENS AVE STE 410
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:443-574-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301109336208600000X
FLME93526208600000X
MDD85603208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1724199OtherCIGNA PROVIDER #
FL276170000Medicaid
FL53238OtherBCBS PROVIDER #
FL7453614OtherAETNA PROVIDER #
FLCE7138OtherMEDICARE GROUP
FLP00449666Medicare PIN
FLI48735Medicare UPIN