Provider Demographics
NPI:1104098656
Name:RENDON, MARIO IVAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:IVAN
Last Name:RENDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 E 30TH ST
Mailing Address - Street 2:AP 8L
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6416
Mailing Address - Country:US
Mailing Address - Phone:212-532-6840
Mailing Address - Fax:212-532-6840
Practice Address - Street 1:333 E 30TH ST
Practice Address - Street 2:AP 8L
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6416
Practice Address - Country:US
Practice Address - Phone:212-532-6840
Practice Address - Fax:212-532-6840
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1153692084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01786447Medicaid