Provider Demographics
NPI:1700849239
Name:MANDL, LISA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:MANDL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4872
Mailing Address - Country:US
Mailing Address - Phone:212-774-2044
Mailing Address - Fax:212-606-1170
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:212-774-2044
Practice Address - Fax:212-606-1170
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226945174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02378816Medicaid
NY02378816Medicaid
NY4073F1Medicare ID - Type Unspecified