Provider Demographics
NPI:1952633927
Name:PAUL E MONDOLFI, MD, PA
Entity Type:Organization
Organization Name:PAUL E MONDOLFI, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-580-1574
Mailing Address - Street 1:605 E SAN ANTONIO ST
Mailing Address - Street 2:SUITE 450 E
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6040
Mailing Address - Country:US
Mailing Address - Phone:361-580-1574
Mailing Address - Fax:361-570-3709
Practice Address - Street 1:605 E SAN ANTONIO ST
Practice Address - Street 2:SUITE 450 E
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6040
Practice Address - Country:US
Practice Address - Phone:361-580-1574
Practice Address - Fax:361-570-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ97612082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089873603Medicaid
TX089873603Medicaid