Provider Demographics
NPI:1861416703
Name:MENDELSOHN, JACQUES (MD)
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:
Last Name:MENDELSOHN
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 1:506 CROMWELL AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-1851
Mailing Address - Country:US
Mailing Address - Phone:860-529-1287
Mailing Address - Fax:860-721-6311
Practice Address - Street 1:506 CROMWELL AVE
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1851
Practice Address - Country:US
Practice Address - Phone:860-529-1287
Practice Address - Fax:860-721-6311
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001205103Medicaid
CT010020510CT01OtherANTHEM BLUE SHIELD
0V3643OtherHELATHNET
CT010020510CT01OtherANTHEM BLUE SHIELD
CT110007520Medicare ID - Type Unspecified