Provider Demographics
NPI:1396852406
Name:MANDL, KENNETH D (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:MANDL
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:CHILDREN'S HOSPITAL BOSTON-DIVISION OF EMERGENCY MED
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5737
Mailing Address - Country:US
Mailing Address - Phone:617-355-6624
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:CHILDREN'S HOSPITAL BOSTON
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5735
Practice Address - Country:US
Practice Address - Phone:617-355-6624
Practice Address - Fax:617-730-0335
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75410208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3107180Medicaid
MA3107180Medicaid
MAJ13554Medicare ID - Type Unspecified