1285635565 NPI number — MRS. TAMARA SIBALIC-MANDIC MD

Table of content: MRS. TAMARA SIBALIC-MANDIC MD (NPI 1285635565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285635565 NPI number — MRS. TAMARA SIBALIC-MANDIC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIBALIC-MANDIC
Provider First Name:
TAMARA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285635565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 LEE LEE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAURENCE HARBOR
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08879-2904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-306-7899
Provider Business Mailing Address Fax Number:
732-654-8856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
88 OLD TOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10304-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-306-7899
Provider Business Practice Location Address Fax Number:
732-654-8856
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  231279 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03405658 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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