Healthcare Provider Details

I. General information

NPI: 1245215441
Provider Name (Legal Business Name): ANIL K. MONGIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E ERIE AVE
PHILADELPHIA PA
19134-1011
US

IV. Provider business mailing address

450 CLARKSON AVE BOX 1262
BROOKLYN NY
11203-2056
US

V. Phone/Fax

Practice location:
  • Phone: 484-628-1324
  • Fax:
Mailing address:
  • Phone: 718-270-8867
  • Fax: 718-270-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD484203
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number002036-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberMD484203
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: