Provider Demographics
NPI:1720092471
Name:MONDI, MATTHEW M (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:M
Last Name:MONDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-854-6008
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:818 SAINT SEBASTIAN WAY STE 104
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2652
Practice Address - Country:US
Practice Address - Phone:706-434-0130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00150208600000X
GA060940208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10409292Medicaid
NC7406921OtherAETNA
WV3810008155Medicaid
NC808466OtherPARTNERS
SCQ0015HMedicaid
NC190681OtherMEDCOST
NC5905895Medicaid
NC1429KOtherBLUE CROSS
SCQ0015HMedicaid
P00435405Medicare PIN