Provider Demographics
NPI:1689838286
Name:MONDERSON, THESSELON WARREN (MD)
Entity Type:Individual
Prefix:
First Name:THESSELON
Middle Name:WARREN
Last Name:MONDERSON
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:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:943-792-6200
Mailing Address - Fax:
Practice Address - Street 1:805 PAMPLICO HWY STE 100
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6047
Practice Address - Country:US
Practice Address - Phone:843-413-6835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-12
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 101703207XS0106X
SC85081207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery