Provider Demographics
NPI:1336247691
Name:MENDELSOHN, FREDERIC A (MD)
Entity type:Individual
Prefix:
First Name:FREDERIC
Middle Name:A
Last Name:MENDELSOHN
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:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-0491
Mailing Address - Country:US
Mailing Address - Phone:631-737-0055
Mailing Address - Fax:631-737-0076
Practice Address - Street 1:650 HAWKINS AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2366
Practice Address - Country:US
Practice Address - Phone:631-737-0055
Practice Address - Fax:631-737-0076
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1126762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00655156Medicaid
NYB20645Medicare UPIN
NY00655156Medicaid