Provider Demographics
NPI:1821058298
Name:MANTELLO, MELINDA (MD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:MANTELLO
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:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12181-0689
Mailing Address - Country:US
Mailing Address - Phone:518-268-5000
Mailing Address - Fax:
Practice Address - Street 1:1 TALLOW WOOD DR
Practice Address - Street 2:SUITE 8
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2807
Practice Address - Country:US
Practice Address - Phone:518-373-4400
Practice Address - Fax:518-383-7330
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02252293Medicaid
NYCC7476Medicare PIN
H44972Medicare UPIN