Provider Demographics
NPI:1790441129
Name:MONGIELLO, ANTHONY JR
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:MONGIELLO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E 2ND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-1214
Mailing Address - Country:US
Mailing Address - Phone:732-804-5756
Mailing Address - Fax:
Practice Address - Street 1:160 E 2ND ST
Practice Address - Street 2:SUITE B
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-1214
Practice Address - Country:US
Practice Address - Phone:732-804-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD1382156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ160244Medicaid