Healthcare Provider Details

I. General information

NPI: 1518812593
Provider Name (Legal Business Name): ZACHARY TYLER MANDEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-1000
  • Fax: 508-856-5911
Mailing address:
  • Phone: 855-862-7763
  • Fax: 508-856-5911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: