Provider Demographics
NPI:1629033428
Name:MANDELBAUM, MARK ALON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALON
Last Name:MANDELBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:573-221-5250
Mailing Address - Fax:573-231-3717
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:573-221-5250
Practice Address - Fax:573-231-3717
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140367632084N0400X
TXJ97482084N0400X
KS04-200412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1629033428Medicaid
MO1629033428Medicaid