Provider Demographics
NPI:1538495825
Name:MONGELLUZZO, JILLIAN (MD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:MONGELLUZZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PARNASSUS AVE.
Mailing Address - Street 2:RM. M-24
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2633
Mailing Address - Country:US
Mailing Address - Phone:415-948-7552
Mailing Address - Fax:
Practice Address - Street 1:505 PARNASSUS AVE RM M-24
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2633
Practice Address - Country:US
Practice Address - Phone:415-948-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-21
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA114713207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine