Provider Demographics
NPI:1275674095
Name:MANDEL, ALISA PERLE (OD)
Entity Type:Individual
Prefix:DR
First Name:ALISA
Middle Name:PERLE
Last Name:MANDEL
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 1:6820 WILLIAMSON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-1549
Mailing Address - Country:US
Mailing Address - Phone:410-963-2977
Mailing Address - Fax:443-394-9511
Practice Address - Street 1:9750 REISTERSTOWN RD
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4147
Practice Address - Country:US
Practice Address - Phone:443-394-7124
Practice Address - Fax:443-394-9511
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1776152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT93021Medicare UPIN