Provider Demographics
NPI:1922167220
Name:MANDELKORN, THEODORE DUNGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:DUNGAN
Last Name:MANDELKORN
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 1:2553 76TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2758
Mailing Address - Country:US
Mailing Address - Phone:206-275-0702
Mailing Address - Fax:
Practice Address - Street 1:2553 76TH AVE SE
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2758
Practice Address - Country:US
Practice Address - Phone:206-275-0702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000107622080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics