Provider Demographics
NPI:1962574269
Name:MANDELL, FREDERICK (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
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 1:850 BOYLSTON STREET
Mailing Address - Street 2:400
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2402
Mailing Address - Country:US
Mailing Address - Phone:617-731-0200
Mailing Address - Fax:617-731-0289
Practice Address - Street 1:850 BOYLSTON STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2402
Practice Address - Country:US
Practice Address - Phone:617-731-0200
Practice Address - Fax:617-731-0289
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33727208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0167541Medicaid
A68122Medicare UPIN