=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609967181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT MANDATO DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2031 N BROAD ST SUITE 107
-----------------------------------------------------
City | LANSDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19446-1063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-855-5854
-----------------------------------------------------
Fax | 215-855-0428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2031 N BROAD ST SUITE 107
-----------------------------------------------------
City | LANSDALE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19446-1063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-855-5854
-----------------------------------------------------
Fax | 215-855-0428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | SC003005L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------