Provider Demographics
NPI:1366531865
Name:PAUL D MANDEL MD SC
Entity type:Organization
Organization Name:PAUL D MANDEL MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-224-7686
Mailing Address - Street 1:5150 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 167
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5474
Mailing Address - Country:US
Mailing Address - Phone:414-224-7686
Mailing Address - Fax:414-224-7685
Practice Address - Street 1:5150 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 167
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5474
Practice Address - Country:US
Practice Address - Phone:414-224-7686
Practice Address - Fax:414-224-7685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23817207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30592500Medicaid
WI000068763Medicare PIN
WIB54795Medicare UPIN
WI30592500Medicaid