Provider Demographics
NPI:1750392783
Name:MANDELBAUM, STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:MANDELBAUM
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 1:381 E SHERIDAN ST APT 301
Mailing Address - Street 2:
Mailing Address - City:DANIA
Mailing Address - State:FL
Mailing Address - Zip Code:33004-5567
Mailing Address - Country:US
Mailing Address - Phone:310-710-8117
Mailing Address - Fax:
Practice Address - Street 1:381 E SHERIDAN ST APT 301
Practice Address - Street 2:
Practice Address - City:DANIA
Practice Address - State:FL
Practice Address - Zip Code:33004-5567
Practice Address - Country:US
Practice Address - Phone:310-710-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1190632084P0804X
CAC530742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4385595Medicaid
MI4385595Medicaid
H60922Medicare UPIN