Provider Demographics
NPI:1134612013
Name:BONGLACK, MILDREDE (MD)
Entity type:Individual
Prefix:
First Name:MILDREDE
Middle Name:
Last Name:BONGLACK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10495 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4468
Mailing Address - Country:US
Mailing Address - Phone:513-865-1631
Mailing Address - Fax:513-865-1632
Practice Address - Street 1:10495 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4468
Practice Address - Country:US
Practice Address - Phone:513-865-1631
Practice Address - Fax:513-865-1632
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-11323207V00000X
OH35.144536207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology