Provider Demographics
NPI:1265842751
Name:MAENDEL, JEFFREY WILLIAM
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:MAENDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W MCCREIGHT AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1890
Mailing Address - Country:US
Mailing Address - Phone:937-717-4884
Mailing Address - Fax:937-717-6207
Practice Address - Street 1:100 W MCCREIGHT AVE STE 110
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1890
Practice Address - Country:US
Practice Address - Phone:937-717-4884
Practice Address - Fax:937-717-6207
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.014029208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program