Healthcare Provider Details

I. General information

NPI: 1912902545
Provider Name (Legal Business Name): JENNIFER E MULLENDORE DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 THOMAS JOHNSON DR STE 204
FREDERICK MD
21702-4557
US

IV. Provider business mailing address

182 THOMAS JOHNSON DRIVE SUITE 204
FREDERICK MD
21702-4557
US

V. Phone/Fax

Practice location:
  • Phone: 301-695-9669
  • Fax: 301-695-0346
Mailing address:
  • Phone: 301-695-9669
  • Fax: 301-695-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number01423
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: