Provider Demographics
NPI:1255838462
Name:MANDESE, MARK VINCENT (LDO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:VINCENT
Last Name:MANDESE
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 GOLDENMOSS LOOP
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4783
Mailing Address - Country:US
Mailing Address - Phone:407-234-5788
Mailing Address - Fax:407-992-7053
Practice Address - Street 1:1717 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2944
Practice Address - Country:US
Practice Address - Phone:407-422-6798
Practice Address - Fax:407-992-7053
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3019156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician