Provider Demographics
NPI:1083950117
Name:ABED AL-MAWLA JANDALI M.D. PC
Entity Type:Organization
Organization Name:ABED AL-MAWLA JANDALI M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABED
Authorized Official - Middle Name:AL-MAWLA
Authorized Official - Last Name:JANDALI PC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-274-4654
Mailing Address - Street 1:13 ARCH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12183-1329
Mailing Address - Country:US
Mailing Address - Phone:518-274-4654
Mailing Address - Fax:518-274-4654
Practice Address - Street 1:13 ARCH ST
Practice Address - Street 2:
Practice Address - City:GREEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:12183-1329
Practice Address - Country:US
Practice Address - Phone:518-274-4654
Practice Address - Fax:518-274-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care