Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | MD047966L | PA |
NPI | 1104984046 |
---|---|
Provider Name | Dr. Mark Mantell |
First Address | Philadelphia, PA 19146-8400 |
Second Address | Philadelphia, PA 19146-8400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |