Provider Demographics
NPI:1477591683
Name:MERNOFF, DAVID BENNET (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BENNET
Last Name:MERNOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1648
Mailing Address - Country:US
Mailing Address - Phone:413-567-5153
Mailing Address - Fax:413-565-4496
Practice Address - Street 1:271 CAREW ST
Practice Address - Street 2:MERCY MEDICAL CENTER, DEPARTMENT OF RADIOLOGY
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2377
Practice Address - Country:US
Practice Address - Phone:413-748-9200
Practice Address - Fax:413-748-9194
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA724432085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3063593Medicaid
MAE65731Medicare UPIN
MA3063593Medicaid