Basic Information
Provider Information | |||||||||
NPI: | 1386643567 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MENDELSON | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MENDELSON | ||||||||
OtherFirstName: | DAVID | ||||||||
OtherMiddleName: | B. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1010 E MCDOWELL RD STE LL1 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850062606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029561250 | ||||||||
FaxNumber: | 6233218620 | ||||||||
Practice Location | |||||||||
Address1: | 1492 S MILL AVE STE 301 | ||||||||
Address2: |   | ||||||||
City: | TEMPE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852815676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808945550 | ||||||||
FaxNumber: | 4808949469 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2005 | ||||||||
LastUpdateDate: | 08/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 3728 | AZ | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YX0905X | 3728 | AZ | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 174400000X | 3728 | AZ | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 698251 | 05 | AZ |   | MEDICAID |