Individual
JACK H MYDLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3401 N BROAD ST, 3RD FLOOR PARKINSON PAVILION, PHILADELPHIA, PA 19140-5103
(215) 707-3375
(215) 707-4758
Mailing address
2450 W HUNTING PARK AVE, PHILADELPHIA, PA 19129-1302
(215) 707-3375
(215) 707-4758
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
MD071004L
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0078049200001
—
PA
Enumeration date
10/12/2005
Last updated
03/21/2017
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