Provider Demographics
NPI:1245257724
Name:MANDELL, KENNETH BRAD (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRAD
Last Name:MANDELL
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 1:15300 JOG RD
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-2162
Mailing Address - Country:US
Mailing Address - Phone:561-455-5601
Mailing Address - Fax:561-455-5601
Practice Address - Street 1:15300 JOG RD
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-2162
Practice Address - Country:US
Practice Address - Phone:561-455-5601
Practice Address - Fax:561-455-5601
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47775XMedicare PIN
I14457Medicare UPIN