Provider Demographics
NPI:1689763203
Name:MANDEL, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MANDEL
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 1:5 JEFFERSON CT
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304 WOOTTON ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1951
Practice Address - Country:US
Practice Address - Phone:973-402-4300
Practice Address - Fax:973-402-0066
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00763200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ082025MYEMedicare ID - Type Unspecified