Provider Demographics
NPI:1770894438
Name:MONDESIR, MONIQUE MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MICHELLE
Last Name:MONDESIR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SW CHAMBER CT STE 101
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3413
Mailing Address - Country:US
Mailing Address - Phone:772-301-0123
Mailing Address - Fax:772-301-0124
Practice Address - Street 1:150 SW CHAMBER CT STE 101
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3413
Practice Address - Country:US
Practice Address - Phone:772-301-0123
Practice Address - Fax:772-301-0124
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115811208000000X
PAMT196440390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009212800Medicaid