Provider Demographics
NPI:1013493220
Name:MONDIE, WEI-SAN
Entity Type:Individual
Prefix:
First Name:WEI-SAN
Middle Name:
Last Name:MONDIE
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 1:1795 S BANNOCK ST APT 7-207
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80223-3631
Mailing Address - Country:US
Mailing Address - Phone:817-891-2936
Mailing Address - Fax:
Practice Address - Street 1:DENVER HEALTH LOWRY FAMILY HEALTH CENTER
Practice Address - Street 2:1001 YOSEMITE ST
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230
Practice Address - Country:US
Practice Address - Phone:303-602-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0007785390200000X, 390200000X
CODR.0065867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018024679Medicaid
CODR.0065867OtherCOLORADO MEDICAL LICENSE