Provider Demographics
NPI:1629064787
Name:MANDELBAUM, JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:
Last Name:MANDELBAUM
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 1:211 HURLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-2400
Mailing Address - Country:US
Mailing Address - Phone:845-339-2804
Mailing Address - Fax:845-339-5058
Practice Address - Street 1:211 HURLEY AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-2400
Practice Address - Country:US
Practice Address - Phone:845-339-2804
Practice Address - Fax:845-339-5058
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129228207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00523588Medicaid
NY00523588Medicaid
NY358131Medicare ID - Type Unspecified