Provider Demographics
NPI:1275609794
Name:MANDESE, MARIA JOY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:JOY
Last Name:MANDESE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-8208
Mailing Address - Country:US
Mailing Address - Phone:407-629-1599
Mailing Address - Fax:407-599-1340
Practice Address - Street 1:5201 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-8208
Practice Address - Country:US
Practice Address - Phone:407-629-1599
Practice Address - Fax:407-599-1340
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007099152W00000X
FLOPC 4406152W00000X
FLOFC32152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621285900Medicaid
FL621285900Medicaid
FLAH445YMedicare UPIN
AH445XMedicare UPIN