Healthcare Provider Details

I. General information

NPI: 1003918277
Provider Name (Legal Business Name): ABED AL-MAWLA JANDALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date: 05/01/2024
Reactivation Date: 05/30/2024

III. Provider practice location address

13 ARCH STREET
GREEN ISLAND NY
12183
US

IV. Provider business mailing address

13 ARCH STREET
GREEN ISLAND NY
12183
US

V. Phone/Fax

Practice location:
  • Phone: 518-274-4654
  • Fax: 518-274-4654
Mailing address:
  • Phone: 518-274-4654
  • Fax: 518-274-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number119867
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number119867
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: