Healthcare Provider Details

I. General information

NPI: 1720085152
Provider Name (Legal Business Name): PAULINE THERESE MONDRAGON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: PAULINE THERESE KOCARNIK

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 W ALAMEDA AVE STE 270
LAKEWOOD CO
80226-3041
US

IV. Provider business mailing address

8015 W ALAMEDA AVE STE 270
LAKEWOOD CO
80226-3041
US

V. Phone/Fax

Practice location:
  • Phone: 303-239-8327
  • Fax: 303-239-9946
Mailing address:
  • Phone: 303-239-8327
  • Fax: 303-239-9946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number193
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: