Healthcare Provider Details

I. General information

NPI: 1134235765
Provider Name (Legal Business Name): JOHN PATRICK MONGAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MEDICAL PARK DR SUITE 200
MALTA NY
12020-5051
US

IV. Provider business mailing address

PO BOX 1368
ALBANY NY
12201-1368
US

V. Phone/Fax

Practice location:
  • Phone: 518-289-2717
  • Fax: 518-886-5247
Mailing address:
  • Phone: 518-289-2717
  • Fax: 518-886-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number248746
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: