Provider Demographics
NPI:1235427360
Name:MANDILE, JACQUELINE L (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:L
Last Name:MANDILE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:LEMOINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:238 NORTHAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-1046
Mailing Address - Country:US
Mailing Address - Phone:413-529-9300
Mailing Address - Fax:866-644-0870
Practice Address - Street 1:238 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1046
Practice Address - Country:US
Practice Address - Phone:413-529-9300
Practice Address - Fax:866-644-0870
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4814152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110089671AMedicaid
MA002315101Medicare PIN