Provider Demographics
NPI:1932920618
Name:MANDELBAUM, STACEY LEE (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:MANDELBAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1241
Mailing Address - Country:US
Mailing Address - Phone:518-796-6338
Mailing Address - Fax:
Practice Address - Street 1:57 WILLOW RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1241
Practice Address - Country:US
Practice Address - Phone:518-796-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173500208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice