Provider Demographics
NPI:1225176878
Name:MENDELSOHN, KENNETH O (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:O
Last Name:MENDELSOHN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 EAST 40TH ST. SUITE 1204
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-986-2153
Mailing Address - Fax:212-986-0398
Practice Address - Street 1:130 EAST 40TH ST. SUITE 1204
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-986-2153
Practice Address - Fax:212-986-0398
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003902-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT48957Medicare UPIN
NYC29921Medicare PIN
NY0320750001Medicare NSC