Provider Demographics
NPI:1215011051
Name:MANTELL, ALAN M (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:M
Last Name:MANTELL
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 1:1818 VERDUGO BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208
Mailing Address - Country:US
Mailing Address - Phone:818-790-3588
Mailing Address - Fax:818-790-6518
Practice Address - Street 1:1818 VERDUGO BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208
Practice Address - Country:US
Practice Address - Phone:818-790-3588
Practice Address - Fax:818-790-6518
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG18862207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG18862Medicare ID - Type Unspecified
A40447Medicare UPIN