Basic Information
| Provider Information | |||||||||
| NPI: | 1194298620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDELBAUM | ||||||||
| FirstName: | SORA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD, LDN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4815 LIBERTY AVE STE 215 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152242156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122355900 | ||||||||
| FaxNumber: | 4122355901 | ||||||||
| Practice Location | |||||||||
| Address1: | 4815 LIBERTY AVE STE 215 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152242156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122355900 | ||||||||
| FaxNumber: | 4122355901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2019 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN006417 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 103597100 | 05 | PA | MEDICAID | 14395489 | 01 | CAQH | OTHER |