Provider Demographics
NPI:1003918277
Name:JANDALI, ABED AL-MAWLA (MD)
Entity Type:Individual
Prefix:
First Name:ABED
Middle Name:AL-MAWLA
Last Name:JANDALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 ARCH STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12183
Mailing Address - Country:US
Mailing Address - Phone:518-274-4654
Mailing Address - Fax:518-274-4654
Practice Address - Street 1:13 ARCH STREET
Practice Address - Street 2:
Practice Address - City:GREEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:12183
Practice Address - Country:US
Practice Address - Phone:518-274-4654
Practice Address - Fax:518-274-4654
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119867208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10002646D252OtherCDPHP
000401344001OtherBLUE SHIELD
NY00525177Medicaid
000401344001OtherBLUE SHIELD
NY00525177Medicaid
31750BMedicare PIN