Healthcare Provider Details

I. General information

NPI: 1083950117
Provider Name (Legal Business Name): ABED AL-MAWLA JANDALI M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 ARCH ST
GREEN ISLAND NY
12183-1329
US

IV. Provider business mailing address

13 ARCH ST
GREEN ISLAND NY
12183-1329
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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ABED AL-MAWLA JANDALI PC
Title or Position: OWNER
Credential: M.D.
Phone: 518-274-4654