Provider Demographics
NPI:1619590262
Name:MARDIT, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MARDIT
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 1:20 PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:RED HOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12571-1008
Mailing Address - Country:US
Mailing Address - Phone:914-582-4434
Mailing Address - Fax:
Practice Address - Street 1:6511 SPRING BROOK AVE
Practice Address - Street 2:
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572-3709
Practice Address - Country:US
Practice Address - Phone:845-876-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY326778207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program