Provider Demographics
NPI:1053913137
Name:MONDRAGON, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:MONDRAGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 PLUM RUN RD
Mailing Address - Street 2:
Mailing Address - City:MANNINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26582-7279
Mailing Address - Country:US
Mailing Address - Phone:304-694-6423
Mailing Address - Fax:
Practice Address - Street 1:311 PLUM RUN RD
Practice Address - Street 2:
Practice Address - City:MANNINGTON
Practice Address - State:WV
Practice Address - Zip Code:26582-7279
Practice Address - Country:US
Practice Address - Phone:304-694-6423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3046946423Medicaid