Healthcare Provider Details

I. General information

NPI: 1720092471
Provider Name (Legal Business Name): MATTHEW M MONDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 SAINT SEBASTIAN WAY STE 104
AUGUSTA GA
30901-2652
US

IV. Provider business mailing address

PO BOX 1705
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-0130
  • Fax:
Mailing address:
  • Phone: 706-854-6008
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2004-00150
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number060940
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: