Healthcare Provider Details

I. General information

NPI: 1184774739
Provider Name (Legal Business Name): SUSAN E MANDEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND ST
NEW BRITIAN CT
06050
US

IV. Provider business mailing address

PO BOX 217 ONE LIBERTY SQUARE
NEW BRITAIN CT
06050-0217
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5556
  • Fax:
Mailing address:
  • Phone: 860-827-0071
  • Fax: 860-229-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number31753
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: