Provider Demographics
NPI:1770580680
Name:MONDINO, JORGE A (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:A
Last Name:MONDINO
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 1:6192 OXON HILL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-3114
Mailing Address - Country:US
Mailing Address - Phone:301-567-2330
Mailing Address - Fax:301-567-2728
Practice Address - Street 1:6192 OXON HILL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3114
Practice Address - Country:US
Practice Address - Phone:301-567-7200
Practice Address - Fax:301-567-2728
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2011-05-03
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
MDD0024059207X00000X
VA0101032472207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00643431Medicaid
MDC62447Medicare UPIN
193346Medicare PIN