Provider Demographics
NPI:1659422582
Name:MANDELBERG, ALAN IRVING (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:IRVING
Last Name:MANDELBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4418 VINELAND AVE
Mailing Address - Street 2:106
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-3457
Mailing Address - Country:US
Mailing Address - Phone:818-762-0647
Mailing Address - Fax:818-762-7834
Practice Address - Street 1:4418 VINELAND AVE
Practice Address - Street 2:#106
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-3457
Practice Address - Country:US
Practice Address - Phone:818-762-0647
Practice Address - Fax:818-762-7834
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG39019207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G390190Medicaid
CA00G390190Medicaid
CA756183937Medicare PIN
CA954435884OtherTIN
CA00G390190Medicaid