Provider Demographics
NPI:1003877101
Name:MADOWICZ, MANDI JOY (RD, CDN, CDE)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:JOY
Last Name:MADOWICZ
Suffix:
Gender:F
Credentials:RD, CDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WAVERLY PL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-2513
Mailing Address - Country:US
Mailing Address - Phone:516-374-1699
Mailing Address - Fax:516-374-1699
Practice Address - Street 1:22 WAVERLY PL
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-2513
Practice Address - Country:US
Practice Address - Phone:516-374-1699
Practice Address - Fax:516-374-1699
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001224133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP49679Medicare UPIN
NY03P461Medicare ID - Type Unspecified