MEDICARE: PAULINE THERESE MONDRAGON P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	193	CO

General Provider Information

NPI Number	:	1720085152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULINE THERESE MONDRAGON P.A.

Provider Business Mailing Address
First Line	:	8015 W ALAMEDA AVE
Second Line	:	STE 270
City	:	LAKEWOOD
State	:	CO
Zip	:	80226-3041
Country	:	US
Telephone Number	:	303-239-8327
Fax Number	:	303-239-9946

Provider Business Practice Location Address
First Line	:	8015 W ALAMEDA AVE
Second Line	:	STE 270
City	:	LAKEWOOD
State	:	CO
Zip	:	80226-3041
Country	:	US
Telephone Number	:	303-239-8327
Fax Number	:	303-239-9946

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/08/2007

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