Healthcare Provider Details

I. General information

NPI: 1851681191
Provider Name (Legal Business Name): JENNIFER MANDELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4277 HEMPSTEAD TPKE SUITE 206
BETHPAGE NY
11714-5709
US

IV. Provider business mailing address

49 E 7TH ST APT 2
NEW YORK NY
10003-8290
US

V. Phone/Fax

Practice location:
  • Phone: 516-731-6505
  • Fax:
Mailing address:
  • Phone: 917-974-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number279856
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: