Provider Demographics
NPI:1427014190
Name:MANDAC, BENJAMIN REYES (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:REYES
Last Name:MANDAC
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 1:710 LAWRENCE EXPY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:408-851-9897
Mailing Address - Fax:408-851-1199
Practice Address - Street 1:710 LAWRENCE EXPY
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5173
Practice Address - Country:US
Practice Address - Phone:408-851-9897
Practice Address - Fax:408-851-1199
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG557902081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G557900Medicaid
CA00G557900Medicare ID - Type Unspecified
CAF15274Medicare UPIN