Provider Demographics
NPI:1720079577
Name:MANDESE, MICHAEL N (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:N
Last Name:MANDESE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 W NASA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-2300
Mailing Address - Country:US
Mailing Address - Phone:321-722-4443
Mailing Address - Fax:321-722-2334
Practice Address - Street 1:1995 W NASA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-2300
Practice Address - Country:US
Practice Address - Phone:321-722-4443
Practice Address - Fax:321-722-2334
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0003023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20761Medicare ID - Type Unspecified
U69495Medicare UPIN