Provider Demographics
NPI:1447318027
Name:MONGILLO, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MONGILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 OLD BROOK RD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-5409
Mailing Address - Country:US
Mailing Address - Phone:508-845-0127
Mailing Address - Fax:
Practice Address - Street 1:14 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3003
Practice Address - Country:US
Practice Address - Phone:508-422-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73402207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine