Healthcare Provider Details

I. General information

NPI: 1033797576
Provider Name (Legal Business Name): MICHELLE YOSHIKO MANDEVILLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 819 BOX 18
FPO AE
09645-0001
US

IV. Provider business mailing address

338 SOUTH DR
SEVERNA PARK MD
21146-2112
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-3305
  • Fax:
Mailing address:
  • Phone: 443-716-5114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101275838
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: