Provider Demographics
NPI:1700821121
Name:MONDELLO FAMILY CLINIC PA
Entity Type:Organization
Organization Name:MONDELLO FAMILY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MONDELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:863-438-9110
Mailing Address - Street 1:PO BOX 552195
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33655-0001
Mailing Address - Country:US
Mailing Address - Phone:863-438-9110
Mailing Address - Fax:863-438-9095
Practice Address - Street 1:1023 SR 542 W
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:FL
Practice Address - Zip Code:33838
Practice Address - Country:US
Practice Address - Phone:863-438-9110
Practice Address - Fax:863-438-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0005695261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0130Medicare PIN