Provider Demographics
NPI:1760516801
Name:MARTIN L MANDEL M. D.,INC
Entity Type:Organization
Organization Name:MARTIN L MANDEL M. D.,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-951-1073
Mailing Address - Street 1:36100 EUCLID AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4456
Mailing Address - Country:US
Mailing Address - Phone:440-951-1073
Mailing Address - Fax:440-951-1844
Practice Address - Street 1:36100 EUCLID AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4456
Practice Address - Country:US
Practice Address - Phone:440-951-1073
Practice Address - Fax:440-951-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000129519OtherANTHEM
OH0332689Medicaid
OH0332689Medicaid
OH000000129519OtherANTHEM