1609518828 NPI number — MANDEL DERMATOLOGY BOULDER PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609518828 NPI number — MANDEL DERMATOLOGY BOULDER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANDEL DERMATOLOGY BOULDER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1609518828
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 NORTHERN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11548-1346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-506-7546
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2575 SPRUCE ST UNIT C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80302-3806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-741-8051
Provider Business Practice Location Address Fax Number:
720-741-8089
Provider Enumeration Date:
04/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
MANDEL
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
720-741-8051

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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