Provider Demographics
NPI:1952477325
Name:MANDEL, SHLOMO S (MD)
Entity Type:Individual
Prefix:
First Name:SHLOMO
Middle Name:S
Last Name:MANDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHLOMO
Other - Middle Name:
Other - Last Name:MANDEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:311 MACK AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-916-2436
Mailing Address - Fax:
Practice Address - Street 1:311 MACK AVE FL 5
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2466
Practice Address - Country:US
Practice Address - Phone:313-916-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010487232083X0100X, 207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3973577OtherMEDICARE PTAN
MI1952477325Medicaid
MI1952477325Medicaid
SM048723OtherCOMMERCIAL-COMMERCIAL NUMBER
SM048723OtherCHAMPUS-CHAMPUS
0H26222106Medicare ID - Type Unspecified