Provider Demographics
NPI:1346545951
Name:NYU MOBILE HEALTH VAN PROGRAM
Entity Type:Organization
Organization Name:NYU MOBILE HEALTH VAN PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-998-9420
Mailing Address - Street 1:726 BROADWAY
Mailing Address - Street 2:10 TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-9502
Mailing Address - Country:US
Mailing Address - Phone:917-696-5626
Mailing Address - Fax:212-995-4243
Practice Address - Street 1:726 BROADWAY
Practice Address - Street 2:10 TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9502
Practice Address - Country:US
Practice Address - Phone:917-696-5626
Practice Address - Fax:212-995-4243
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW YORK UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty