Provider Demographics
NPI:1023781812
Name:MONDRAGON, MICKEY (DC)
Entity type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:
Last Name:MONDRAGON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 SAN PEDRO DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4101
Mailing Address - Country:US
Mailing Address - Phone:505-403-6512
Mailing Address - Fax:
Practice Address - Street 1:2441 SAN PEDRO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4101
Practice Address - Country:US
Practice Address - Phone:505-403-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDC2250111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor