Provider Demographics
NPI:1164413662
Name:MANDOUR, WILLIAM A (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:MANDOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:W
Other - Middle Name:ANTHONY
Other - Last Name:MANDOUR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1226 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1155
Mailing Address - Country:US
Mailing Address - Phone:315-478-4185
Mailing Address - Fax:315-478-0840
Practice Address - Street 1:2 ELLINWOOD DR
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1102
Practice Address - Country:US
Practice Address - Phone:315-724-1012
Practice Address - Fax:315-724-5219
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125882208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00597879Medicaid
NY1164413662Medicare NSC
NYD74921Medicare UPIN