Provider Demographics
NPI:1922032788
Name:MANDELL, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:MANDELL
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 1:140 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-1550
Mailing Address - Country:US
Mailing Address - Phone:978-475-4202
Mailing Address - Fax:
Practice Address - Street 1:ANDOVER SURGICAL ASSOC
Practice Address - Street 2:140 HAVERHILL STREET
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3402
Practice Address - Country:US
Practice Address - Phone:978-475-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79849208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
J30780Medicare Oscar/Certification