Provider Demographics
NPI:1912088063
Name:MANDERNACH, MOLLY HELEN WEIDNER (MD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:HELEN WEIDNER
Last Name:MANDERNACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:HELEN
Other - Last Name:WEIDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:352-273-7832
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER ROAD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610
Practice Address - Country:US
Practice Address - Phone:352-273-7832
Practice Address - Fax:352-273-7849
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97424207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005939200Medicaid
FL005939200Medicaid