Provider Demographics
NPI:1013966944
Name:MANDELCORN, MARK SAMUEL (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:SAMUEL
Last Name:MANDELCORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:301 STERLING DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1570
Mailing Address - Country:US
Mailing Address - Phone:716-677-6500
Mailing Address - Fax:716-677-6507
Practice Address - Street 1:301 STERLING DRIVE
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1570
Practice Address - Country:US
Practice Address - Phone:716-677-6500
Practice Address - Fax:716-677-6507
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188981207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000511371002OtherHEALTH NOW NEW YORK
NY0807246OtherINDEPENDENT HEALTH
NY01843109Medicaid
BB8608Medicare ID - Type Unspecified
NY01843109Medicaid