Healthcare Provider Details

I. General information

NPI: 1821452624
Provider Name (Legal Business Name): BRANDON JAMES MONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5246 BRITTANY DR LSU OLOL EMERGENCY MEDICINE
BATON ROUGE LA
70808
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 225-757-4210
  • Fax: 225-757-4230
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number307578
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: