Healthcare Provider Details

I. General information

NPI: 1902450844
Provider Name (Legal Business Name): MIRELLA MENDOZA CHIPONGIAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 10/28/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3965 TAFUNA
PAGO PAGO AS- AMERICAN SAMOA
96799
US

IV. Provider business mailing address

PO BOX 3393
PAGO PAGO AS - AMERICAN SAMOA
96799
US

V. Phone/Fax

Practice location:
  • Phone: 684-699-6380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4113C
License Number StateAS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: