Provider Demographics
NPI:1962590125
Name:MANDEL, JORDAN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:MANDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 W LOOMIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4823
Mailing Address - Country:US
Mailing Address - Phone:414-433-1000
Mailing Address - Fax:414-433-0195
Practice Address - Street 1:4710 W LOOMIS RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4823
Practice Address - Country:US
Practice Address - Phone:414-433-1000
Practice Address - Fax:414-433-0195
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32480208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31878700Medicaid
WIF44603Medicare UPIN
WI31878700Medicaid