Basic Information
| Provider Information | |||||||||
| NPI: | 1093807752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDELBLUM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3255 FOREST HILL BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619644577 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3255 FOREST HILL BLVD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619644577 | ||||||||
| FaxNumber: | 5619647772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0073551 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008445500 | 05 | FL | MEDICAID |