Healthcare Provider Details

I. General information

NPI: 1578975363
Provider Name (Legal Business Name): JASON G. MANDELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 07/07/2023
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-2916
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 631
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-6108
  • Fax:
Mailing address:
  • Phone: 585-275-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD045139
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number309047
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number309047
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number309047
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: