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NPI Code Detail

MEDICARE: MANDEL JOHNSON SMITH RD

MEDICARE: MANDEL JOHNSON SMITH RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered DietitianDN006633PA
2207RE0101XEndocrinology, Diabetes & Metabolism PhysicianDN006633PA

General Provider Information

NPI Number : 1083453260
Entity Type Code : Individual
Provider Name (Legal Business Name) : MANDEL JOHNSON SMITH RD
Provider Business Mailing Address
First Line : 3509 N BROAD ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19140-4105
Country : US
Telephone Number : 215-707-2433
Fax Number :
Provider Business Practice Location Address
First Line : 3401 N BROAD ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19140-5103
Country : US
Telephone Number : 215-707-4600
Fax Number : 215-707-5599
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/20/2024
Last Update Date : 02/02/2026

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Directions to “ MANDEL JOHNSON SMITH RD” Practice Location

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