Provider Demographics
NPI:1366233728
Name:MYLOD, MADELINE (DO)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:MYLOD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1818
Mailing Address - Country:US
Mailing Address - Phone:518-928-0262
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT024246208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery