Provider Demographics
NPI:1407069818
Name:MANDRAS, STACY ALLISON (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ALLISON
Last Name:MANDRAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 N ORANGE AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5521
Mailing Address - Country:US
Mailing Address - Phone:407-303-2474
Mailing Address - Fax:407-303-0680
Practice Address - Street 1:2415 N ORANGE AVE STE 700
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5521
Practice Address - Country:US
Practice Address - Phone:407-303-2474
Practice Address - Fax:407-303-0680
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203226207RA0001X, 207RC0000X
MO2006015684207RC0000X
FLME144091207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1889938Medicaid
MS07720531Medicaid
MO2006015684OtherLICENSE NUMBER
LA4M298Medicare PIN
LA4M2987061Medicare PIN