Provider Demographics
NPI:1578542254
Name:MANDULEY, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MANDULEY
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 1:66 WEST GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NY
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:125 PATERSON STREET
Practice Address - Street 2:SUITE 6140 CAB
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:732-235-7905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA059797002080P0202X
NY1794092080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01550678Medicaid
NJ25MA05979700OtherNJ LICENSE
NJ6238700Medicaid
NY29K991Medicare ID - Type Unspecified
NY01550678Medicaid
NJ6238700Medicaid
NJ204006C53Medicare PIN