Provider Demographics
NPI:1164510657
Name:MENDELSON, SUSANA L (RD, CDE)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:L
Last Name:MENDELSON
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 413
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-0413
Mailing Address - Country:US
Mailing Address - Phone:201-637-2631
Mailing Address - Fax:973-696-2433
Practice Address - Street 1:330 GRAND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-2728
Practice Address - Country:US
Practice Address - Phone:201-637-2631
Practice Address - Fax:973-696-2433
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ871383133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ054092UVHMedicare PIN