Provider Demographics
NPI:1639674930
Name:SONBOL, MONA MOSTAFA
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:MOSTAFA
Last Name:SONBOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 GOLDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4215
Mailing Address - Country:US
Mailing Address - Phone:763-588-0661
Mailing Address - Fax:
Practice Address - Street 1:3833 COON RAPIDS BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2697
Practice Address - Country:US
Practice Address - Phone:763-427-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN734822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program