Provider Demographics
NPI:1467624296
Name:RICHARD MANDELBAUM MD PC
Entity Type:Organization
Organization Name:RICHARD MANDELBAUM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:I
Authorized Official - Last Name:MANDELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-384-6365
Mailing Address - Street 1:164 CLYMER ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-7104
Mailing Address - Country:US
Mailing Address - Phone:718-384-6365
Mailing Address - Fax:206-202-2774
Practice Address - Street 1:164 CLYMER ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7104
Practice Address - Country:US
Practice Address - Phone:718-384-6365
Practice Address - Fax:206-202-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206316174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1407887805OtherNPI
NY01817972Medicaid
G71728OtherUPIN
G71728OtherUPIN