Healthcare Provider Details

I. General information

NPI: 1578542254
Provider Name (Legal Business Name): ROBERT MANDULEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PATERSON STREET SUITE 6140 CAB
NEW BRUNSWICK NJ
08901
US

IV. Provider business mailing address

66 WEST GILBERT ST
RED BANK NY
07701
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-7905
  • Fax:
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number25MA05979700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number179409
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: