Provider Demographics
NPI:1316929573
Name:MON, MANUEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:J
Last Name:MON
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 1:13740 CYPRESS TERRACE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-8827
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:9350 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7980
Practice Address - Country:US
Practice Address - Phone:239-481-5437
Practice Address - Fax:239-481-1902
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35526208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065979700Medicaid
FL208895OtherAVMED
FL000013683BOtherHUMANA
FL27100OtherSTAYWELL
FL36303OtherBC/BS OF FLORIDA
FL000013683BOtherHUMANA
FL36303ZMedicare ID - Type Unspecified