Healthcare Provider Details

I. General information

NPI: 1427014190
Provider Name (Legal Business Name): BENJAMIN REYES MANDAC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 08/15/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 LAWRENCE EXPY
SANTA CLARA CA
95051-5173
US

IV. Provider business mailing address

1558 GUADALAJARA DR
SAN JOSE CA
95120-4814
US

V. Phone/Fax

Practice location:
  • Phone: 408-851-5000
  • Fax:
Mailing address:
  • Phone: 408-833-5129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberG55790
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG55790
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: