Provider Demographics
NPI:1669408696
Name:MANDELBAUM, DAVID E (MD, PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:MANDELBAUM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5518
Mailing Address - Country:US
Mailing Address - Phone:401-595-3467
Mailing Address - Fax:
Practice Address - Street 1:1 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504-8901
Practice Address - Country:US
Practice Address - Phone:203-785-4081
Practice Address - Fax:203-737-7635
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151239208000000X, 2084N0402X, 2084N0600X
RIMD110652084N0402X, 2084N0600X, 2084P0005X
CT643352084N0402X
MN701472084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1669408696Medicaid
RIE13273Medicare UPIN
RI007010273Medicare ID - Type Unspecified