Provider Demographics
NPI:1033222823
Name:MANDULEY, ARIEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:ARIEL
Middle Name:M
Last Name:MANDULEY
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 1:15175 EAGLE NEST LN
Mailing Address - Street 2:SUITE #108
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2244
Mailing Address - Country:US
Mailing Address - Phone:305-824-1107
Mailing Address - Fax:305-558-0570
Practice Address - Street 1:15175 EAGLE NEST LN
Practice Address - Street 2:SUITE #108
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2244
Practice Address - Country:US
Practice Address - Phone:305-824-1107
Practice Address - Fax:305-558-0570
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL95268WMedicare ID - Type Unspecified
FL95268XMedicare ID - Type Unspecified
FLD63393Medicare UPIN